1
|
Parker SH, Jesso MN, Wolf LD, Leigh KA, Booth S, Gualandi N, Garrick RE, Kliger AS, Patel PR. Human Factors Contributing to Infection Prevention in Outpatient Hemodialysis Centers: A Mixed Methods Study. Am J Kidney Dis 2024; 84:18-27. [PMID: 38447708 PMCID: PMC11193600 DOI: 10.1053/j.ajkd.2023.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 12/18/2023] [Accepted: 12/23/2023] [Indexed: 03/08/2024]
Abstract
RATIONALE & OBJECTIVE Infection prevention efforts in dialysis centers can avert patient morbidity and mortality but are challenging to implement. The objective of this study was to better understand how the design of the work system might contribute to infection prevention in outpatient dialysis centers. STUDY DESIGN Mixed methods, observational study. SETTING & PARTICIPANTS Six dialysis facilities across the United States visited by a multidisciplinary team over 8 months. ANALYTICAL APPROACH At each facility, structured macroergonomic observations were undertaken by a multidisciplinary team using the SEIPS 1.0 model. Ethnographic observations were collected about staff encounters with dialysis patients including the content of staff conversations. Selective and axial coding were used for qualitative analysis and quantitative data were reported using descriptive statistics. RESULTS Organizational and sociotechnical barriers and facilitators to infection prevention in the outpatient dialysis setting were identified. Features related to human performance, (eg, alarms, interruptions, and task stacking), work system design (eg, physical space, scheduling, leadership, and culture), and extrinsic factors (eg, patient-related characteristics) were identified. LIMITATIONS This was an exploratory evaluation with a small sample size. CONCLUSIONS This study used a systematic macroergonomic approach in multiple outpatient dialysis facilities to identify infection prevention barriers and facilitators related to human performance. Several features common across facilities were identified that may influence infection prevention in outpatient care and warrant further exploration.
Collapse
Affiliation(s)
| | | | | | | | - Stephanie Booth
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Nicole Gualandi
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Renee E Garrick
- New York Medical and Westchester Medical Center, Valhalla, New York
| | - Alan S Kliger
- Department of Medicine, Section of Nephrology, School of Medicine, Yale University, New Haven, Connecticut
| | - Priti R Patel
- Centers for Disease Control and Prevention, Atlanta, Georgia
| |
Collapse
|
2
|
Rotenstein L, Wang H, West CP, Dyrbye LN, Trockel M, Sinsky C, Shanafelt T. Teamwork Climate, Safety Climate, and Physician Burnout: A National, Cross-Sectional Study. Jt Comm J Qual Patient Saf 2024; 50:458-462. [PMID: 38653613 DOI: 10.1016/j.jcjq.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 03/06/2024] [Accepted: 03/07/2024] [Indexed: 04/25/2024]
|
3
|
Hempel S, Bolshakova M, Hochman M, Jimenez E, Thompson G, Motala A, Ganz DA, Gabrielian S, Edwards S, Zenner J, Dennis B, Chang E. Caring for high-need patients. BMC Health Serv Res 2023; 23:1289. [PMID: 37996845 PMCID: PMC10668484 DOI: 10.1186/s12913-023-10236-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 10/28/2023] [Indexed: 11/25/2023] Open
Abstract
OBJECTIVE We aimed to explore the construct of "high need" and identify common need domains among high-need patients, their care professionals, and healthcare organizations; and to describe the interventions that health care systems use to address these needs, including exploring the potential unintended consequences of interventions. METHODS We conducted a modified Delphi panel informed by an environmental scan. Expert stakeholders included patients, interdisciplinary healthcare practitioners (physicians, social workers, peer navigators), implementation scientists, and policy makers. The environmental scan used a rapid literature review and semi-structured interviews with key informants who provide healthcare for high-need patients. We convened a day-long virtual panel meeting, preceded and followed by online surveys to establish consensus. RESULTS The environmental scan identified 46 systematic reviews on high-need patients, 19 empirical studies documenting needs, 14 intervention taxonomies, and 9 studies providing construct validity for the concept "high need." Panelists explored the construct and terminology and established that individual patients' needs are unique, but areas of commonality exist across all high-need patients. Panelists agreed on 11 domains describing patient (e.g., social circumstances), 5 care professional (e.g., communication), and 8 organizational (e.g., staffing arrangements) needs. Panelists developed a taxonomy of interventions with 15 categories (e.g., care navigation, care coordination, identification and monitoring) directed at patients, care professionals, or the organization. The project identified potentially unintended consequences of interventions for high-need patients, including high costs incurred for patients, increased time and effort for care professionals, and identification of needs without resources to respond appropriately. CONCLUSIONS Care for high-need patients requires a thoughtful approach; differentiating need domains provides multiple entry points for interventions directed at patients, care professionals, and organizations. Implementation efforts should consider outlined intended and unintended downstream effects on patients, care professionals, and organizations.
Collapse
Affiliation(s)
- Susanne Hempel
- Southern California Evidence Review Center, University of Southern California, Los Angeles, USA.
| | - Maria Bolshakova
- Southern California Evidence Review Center, University of Southern California, Los Angeles, USA
| | - Michael Hochman
- Gehr Family Center for Health Systems Science and Innovation, University of Southern California, Los Angeles, CA, USA
| | - Elvira Jimenez
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Gina Thompson
- Southern California Evidence Review Center, University of Southern California, Los Angeles, USA
| | - Aneesa Motala
- Southern California Evidence Review Center, University of Southern California, Los Angeles, USA
| | - David A Ganz
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | | | | | - James Zenner
- Los Angeles County Department of Mental Health, Los Angeles, CA, USA
| | - Ben Dennis
- Southern California Evidence Review Center, University of Southern California, Los Angeles, USA
| | - Evelyn Chang
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| |
Collapse
|
4
|
Affiliation(s)
- Alan J Card
- From the Department of Pediatrics, University of California, San Diego, School of Medicine, La Jolla, CA
| |
Collapse
|
5
|
Zandbiglari K, Hasanzadeh HR, Kotecha P, Sajdeya R, Goodin AJ, Jiao T, Adiba FI, Mardini MT, Bian J, Rouhizadeh M. A Natural Language Processing Algorithm for Classifying Suicidal Behaviors in Alzheimer's Disease and Related Dementia Patients: Development and Validation Using Electronic Health Records Data. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.07.21.23292976. [PMID: 37546764 PMCID: PMC10402223 DOI: 10.1101/2023.07.21.23292976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
This study aimed to develop a natural language processing algorithm (NLP) using machine learning (ML) and Deep Learning (DL) techniques to identify and classify documentation of suicidal behaviors in patients with Alzheimer's disease and related dementia (ADRD). We utilized MIMIC-III and MIMIC-IV datasets and identified ADRD patients and subsequently those with suicide ideation using relevant International Classification of Diseases (ICD) codes. We used cosine similarity with ScAN (Suicide Attempt and Ideation Events Dataset) to calculate semantic similarity scores of ScAN with extracted notes from MIMIC for the clinical notes. The notes were sorted based on these scores, and manual review and categorization into eight suicidal behavior categories were performed. The data were further analyzed using conventional ML and DL models, with manual annotation as a reference. The tested classifiers achieved classification results close to human performance with up to 98% precision and 98% recall of suicidal ideation in the ADRD patient population. Our NLP model effectively reproduced human annotation of suicidal ideation within the MIMIC dataset. These results establish a foundation for identifying and categorizing documentation related to suicidal ideation within ADRD population, contributing to the advancement of NLP techniques in healthcare for extracting and classifying clinical concepts, particularly focusing on suicidal ideation among patients with ADRD. Our study showcased the capability of a robust NLP algorithm to accurately identify and classify documentation of suicidal behaviors in ADRD patients.
Collapse
|
6
|
Bardach NS, Stotts JR, Fiore DM, Sarkar U, Sharma AE, Boscardin WJ, Avina L, Peralta-Neel C, Rosenbluth G. Family Input for Quality and Safety (FIQS): Using mobile technology for in-hospital reporting from families and patients. J Hosp Med 2022; 17:456-465. [PMID: 35535946 DOI: 10.1002/jhm.2777] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 12/29/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Despite three decades of effort, ensuring inpatient safety remains elusive. Patients and family members are a potential source of safety observations, but systems gathering these are limited. Our goal was to test a system to gather safety observations from hospitalized patients and their family members via a real-time mobile health tool. METHODS We developed a mobile-responsive website for reporting safety observations. We piloted the tool during June 2017-April 2018 on the medical-surgical unit of a children's hospital. Participants were English-speaking family members and patients ≥13 years. We sent a daily text with a website link. We assessed: (1) face validity by comparing observations to incident reporting (IR) criteria and to hospital IRs and (2) associations between the number of safety observations/100 patient-days and participant characteristics using Poisson regression. RESULTS We enrolled 235 patients (43.8% of 537 reviewed for eligibility), resulting in 8.15 safety reports/100 patient-days, most frequently regarding medications (29% of reports) and communication (20% of reports). Fifty-one (40% of 125) met IR criteria; only one (1.1%) had been reported via the IR system. Latinx participants submitted fewer observations than White participants (3.9 vs. 10.1, p = .002); participants with more prior hospitalizations submitted more observations (p < .001). In adjusted analyses, including measures of preference in decision making, and patient activation, the difference between Latinx and White participants diminished substantially (6.4 vs. 11.3, p = .16). CONCLUSIONS We demonstrated the feasibility of real-time patient and family-member technology-enabled safety observation reporting and elicited reports not otherwise identified. Variation in reporting may potentially exacerbate disparities in safety if not addressed.
Collapse
Affiliation(s)
- Naomi S Bardach
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, USA
| | - Jim R Stotts
- Department of Patient Safety and Regulatory Affairs, University of California San Francisco, San Francisco, California, USA
| | - Darren M Fiore
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Urmimala Sarkar
- Division of General Internal Medicine, University of California San Francisco, San Francisco, California, USA
- Department of Medicine, UCSF Center for Vulnerable Populations, University of California San Francisco, San Francisco, California, USA
| | - Anjana E Sharma
- Department of Medicine, UCSF Center for Vulnerable Populations, University of California San Francisco, San Francisco, California, USA
- Department of Family and Community Medicine, University of California San Francisco, San Francisco, California, USA
| | - W John Boscardin
- Departments of Medicine and Epidemiology & Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Lizette Avina
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, USA
| | - Caroline Peralta-Neel
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, USA
| | - Glenn Rosenbluth
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
7
|
Scaling up Quality Improvement for Surgical Teams (QIST)—avoiding surgical site infection and anaemia at the time of surgery: a cluster randomised controlled trial of the effectiveness of quality improvement collaboratives to introduce change in the NHS. Implement Sci 2022; 17:22. [PMID: 35279171 PMCID: PMC8917366 DOI: 10.1186/s13012-022-01193-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 01/24/2022] [Indexed: 11/12/2022] Open
Abstract
Background The aim of this trial was to assess the effectiveness of quality improvement collaboratives to implement large-scale change in the National Health Service (NHS) in the UK, specifically for improving outcomes in patients undergoing primary, elective total hip or knee replacement. Methods We undertook a two-arm, cluster randomised controlled trial comparing the roll-out of two preoperative pathways: methicillin-sensitive Staphylococcus aureus (MSSA) decolonisation (infection arm) and anaemia screening and treatment (anaemia arm). NHS Trusts are public sector organisations that provide healthcare within a geographical area. NHS Trusts (n = 41) in England providing primary, elective total hip and knee replacements, but that did not have a preoperative anaemia screening or MSSA decolonisation pathway in place, were randomised to one of the two parallel collaboratives. Collaboratives took place from May 2018 to November 2019. Twenty-seven Trusts completed the trial (11 anaemia, 16 infection). Outcome data were collected for procedures performed between November 2018 and November 2019. Co-primary outcomes were perioperative blood transfusion (within 7 days of surgery) and deep surgical site infection (SSI) caused by MSSA (within 90 days post-surgery) for the anaemia and infection trial arms, respectively. Secondary outcomes were deep and superficial SSIs (any organism), length of hospital stay, critical care admissions and unplanned readmissions. Process measures included the proportion of eligible patients receiving each preoperative initiative. Results There were 19,254 procedures from 27 NHS Trusts included in the results (6324 from 11 Trusts in the anaemia arm, 12,930 from 16 Trusts in the infection arm). There were no improvements observed for blood transfusion (anaemia arm 183 (2.9%); infection arm 302 (2.3%) transfusions; adjusted odds ratio 1.20, 95% CI 0.52–2.75, p = 0.67) or MSSA deep SSI (anaemia arm 8 (0.13%); infection arm 18 (0.14%); adjusted odds ratio 1.01, 95% CI 0.42–2.46, p = 0.98). There were no significant improvements in any secondary outcome. This is despite process measures showing the preoperative pathways were implemented for 73.7% and 61.1% of eligible procedures in the infection and anaemia arms, respectively. Conclusions Quality improvement collaboratives did not result in improved patient outcomes in this trial; however, there was some evidence they may support successful implementation of new preoperative pathways in the NHS. Trial registration Prospectively registered on 15 February 2018, ISRCTN11085475 Supplementary Information The online version contains supplementary material available at 10.1186/s13012-022-01193-9.
Collapse
|
8
|
Manojlovich M, Hofer TP, Krein SL. Advancing Patient Safety Through the Clinical Application of a Framework Focused on Communication. J Patient Saf 2021; 17:e732-e737. [PMID: 30383622 DOI: 10.1097/pts.0000000000000547] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The study of communication has evolved from diverse academic disciplines, yet those diverse fields are not well represented in theoretical frameworks that describe communication in health care, narrowing our ability to explain how communication affects patient safety. The purpose of this review article is to describe a conceptual framework of communication drawn from multiple academic disciplines and apply it to health care, specifically for examining communication between providers about the clinical care of their patients. METHODS A seminal article in the field of communication that attempted to map the entire field of communication theory inspired our conceptual framework. We adapted these concepts, largely from the social science literature, to find alternative ways of conceptualizing communication and ways to enhance communication in health care. RESULTS There are 8 theoretical traditions that informed our conceptual framework: rhetorical, phenomenological, semiotic, cybernetic, sociopsychological, sociocultural, critical, and pragmatic. We provide practical, clinical applications of our conceptual framework, encompassing the interpersonal nature of communication, relationship building and trust, hierarchical differences, and the role of technology in communication. In adopting our conceptual framework, we suggest that researchers and clinicians can choose from any combination of these 8 theoretical traditions to more fully describe and ultimately enhance communication-related phenomena. CONCLUSIONS Poor communication remains a stubborn problem in health care in part because of a narrow theoretical and definitional approach to resolving it. Our conceptual framework suggests ways to build relationships and trust, addresses hierarchical differences between communicators, and illuminates the role of technology in communication. It also importantly expands the definition of the value of communication beyond simple information exchange to include creation of new knowledge during communication through the development of shared understanding.
Collapse
|
9
|
Henriksen K, Rodrick D, Grace EN, Shofer M, Jeffrey Brady P. Pursuing Patient Safety at the Intersection of Design, Systems Engineering, and Health Care Delivery Research: An Ongoing Assessment. J Patient Saf 2021; 17:e1685-e1690. [PMID: 30747860 DOI: 10.1097/pts.0000000000000577] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Despite endorsements for greater use of systems approaches and reports from national consensus bodies calling for closer engineering/health care partnerships to improve care delivery, there has been a scarcity of effort of actually engaging the design and engineering disciplines in patient safety projects. The article describes a grant initiative undertaken by the Agency for of Healthcare Research and Quality that brings these disciplines together to test new ideas that could make health care safer. METHODS Collectively known as patient safety learning laboratories, grantee teams engage in phase-based activities that parallel a systems engineering process-problem analysis, design, development, implementation, and evaluation-to gain an in-depth understanding of related patient safety problems, generate fresh ideas and rapid prototypes, develop the prototypes, ensure that developed components are implemented as an integrated working system, and evaluate the system in a simulated or clinical setting. FINDINGS Obstacles are described that can derail the best of intentions in deploying the systems engineering methodology. Based on feedback received from project teams, lessons learned are emerging that find considerable variation among project teams in deploying the methodology and a longer than anticipated amount of time in bringing team members from different disciplines together where they learn to communicate and function as a team. CONCLUSIONS Three narratives are generated in terms of what success might look like. Much is yet to be learned about the limitations and successes of the ongoing learning laboratory initiative, which should be relevant to the broader scale interest in learning health systems.
Collapse
Affiliation(s)
- Kerm Henriksen
- From the Center for Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality, Rockville, Maryland
| | | | | | | | | |
Collapse
|
10
|
Damery S, Flanagan S, Jones J, Jolly K. The Effect of Providing Staff Training and Enhanced Support to Care Homes on Care Processes, Safety Climate and Avoidable Harms: Evaluation of a Care Home Quality Improvement Programme in England. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18147581. [PMID: 34300034 PMCID: PMC8307011 DOI: 10.3390/ijerph18147581] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 07/12/2021] [Accepted: 07/14/2021] [Indexed: 11/22/2022]
Abstract
Older people living in care homes are at risk from avoidable harms, which may require hospital attendance or admission. This paper describes a mixed methods evaluation of a large quality improvement (QI) programme that provides skills training and facilitated support to staff in 29 care homes across two localities in the West Midlands, UK. The Safety Attitudes Questionnaire (SAQ) is used to assess changes to care home safety climate between baseline and programme end at 24 months. We use routinely collected data to assess pre- and post-programme avoidable harms and hospital attendance/admission rates. Semi-structured interviews with programme managers (n = 18), and staff (n = 49) in four case study homes are also used to assess perspectives on programme implementation. Our results show that safety climate scores increase by 1.4 points. There are significant reductions in falls (p = 0.0006), severe pressure ulcers (p = 0.014), UTIs (p = 0.001) and ‘any’ events (p = 0.0003). Emergency hospital attendances reduced, but admissions increased. Interview participants report improvements to teamwork, working practices, information sharing, knowledge and skills. Upskilling care home staff can improve working practices and attitudes towards resident safety and care quality, which may be associated with significant reductions in avoidable harms rates. Care staff turnover rates are high, which may impact the potential for longer-term sustainability of the changes observed.
Collapse
|
11
|
Musuuza JS, Fong E, Lata P, Willenborg K, Knobloch MJ, Hoernke MJ, Spiel AR, Tischendorf JS, Suda KJ, Safdar N. Feasibility of a pharmacy-led intervention to de-implement non-guideline-concordant proton pump inhibitor use. Implement Sci Commun 2021; 2:59. [PMID: 34074337 PMCID: PMC8171048 DOI: 10.1186/s43058-021-00161-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 05/19/2021] [Indexed: 11/21/2022] Open
Abstract
Background Proton pump inhibitors (PPIs) are among the most prescribed medications and are often used unnecessarily. PPIs are used for the treatment of heartburn and acid-related disorders. Emerging evidence indicates that PPIs are associated with serious adverse events, such as increased risk of Clostridioides difficile infection. In this study, we designed and piloted a PPI de-implementation intervention among hospitalized non-intensive care unit patients. Methods Using the Systems Engineering Initiative for Patient Safety (SEIPS) model as the framework, we developed an intervention with input from providers and patients. On a bi-weekly basis, a trainee pharmacist reviewed a random sample of eligible patients’ charts to assess if PPI prescriptions were guideline-concordant; a recommendation to de-implement non-guideline-concordant PPI therapy was sent when applicable. We used convergent parallel mixed-methods design to evaluate the feasibility and outcomes of the intervention. Results During the study period (September 2019 to August 2020), 2171 patients with an active PPI prescription were admitted. We randomly selected 155 patient charts for review. The mean age of patients was 70.9 ± 9 years, 97.4% were male, and 35% were on PPIs for ≥5 years. The average time (minutes) needed to complete the intervention was as follows: 5 to assess if the PPI was guideline-concordant, 5 to provide patient education, and 7 to follow-up with patients post-discharge. After intervention initiation, the week-to-week mean number of PPI prescriptions decreased by 0.5 (S<0.0001). Barriers and facilitators spanned the 5 elements of the SEIPS model and included factors such as providers’ perception that PPIs are low priority medications and patients’ willingness to make changes to their PPI therapy if needed, respectively. Ready access to pharmacists was another frequently reported facilitator to guideline-concordant PPI. Providers recommended a PPI de-implementation intervention that is specific and tells them exactly what they need to do with a PPI treatment. Conclusion In a busy inpatient setting, we developed a feasible way to assess PPI therapy, de-implement non-guideline-concordant PPI use, and provide follow-up to assess any unintended consequences. We documented barriers, facilitators, and provider recommendations that should be considered before implementing such an intervention on a large scale. Supplementary Information The online version contains supplementary material available at 10.1186/s43058-021-00161-6.
Collapse
Affiliation(s)
- Jackson S Musuuza
- William S. Middleton Memorial Veterans Hospital, Madison, WI, USA. .,Division of Infectious Disease, Department of Medicine, University of Wisconsin School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA.
| | - Emily Fong
- William S. Middleton Memorial Veterans Hospital, Madison, WI, USA.,School of Pharmacy, University of Wisconsin School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Paul Lata
- William S. Middleton Memorial Veterans Hospital, Madison, WI, USA
| | - Katie Willenborg
- William S. Middleton Memorial Veterans Hospital, Madison, WI, USA
| | - Mary Jo Knobloch
- William S. Middleton Memorial Veterans Hospital, Madison, WI, USA.,Division of Infectious Disease, Department of Medicine, University of Wisconsin School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Margaret J Hoernke
- William S. Middleton Memorial Veterans Hospital, Madison, WI, USA.,School of Pharmacy, University of Wisconsin School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Andrew R Spiel
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Jessica S Tischendorf
- William S. Middleton Memorial Veterans Hospital, Madison, WI, USA.,Division of Infectious Disease, Department of Medicine, University of Wisconsin School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Katie J Suda
- VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.,Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Nasia Safdar
- William S. Middleton Memorial Veterans Hospital, Madison, WI, USA.,Division of Infectious Disease, Department of Medicine, University of Wisconsin School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| |
Collapse
|
12
|
Knobloch MJ, Musuuza JS, McKinley L, Zimbric ML, Baubie K, Hundt AS, Carayon P, Hagle M, Pfeiffer CD, Galea MD, Crnich CJ, Safdar N. Implementing daily chlorhexidine gluconate (CHG) bathing in VA settings: The human factors engineering to prevent resistant organisms (HERO) project. Am J Infect Control 2021; 49:775-783. [PMID: 33359552 DOI: 10.1016/j.ajic.2020.12.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 12/12/2020] [Accepted: 12/21/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Daily use of chlorhexidine gluconate (CHG) has been shown to reduce risk of healthcare-associated infections. We aimed to assess moving CHG bathing into routine practice using a human factors approach. We evaluated implementation in non-intensive care unit (ICU) settings in the Veterans Health Administration. METHODS Our multiple case study approach included non-ICU units from 4 Veterans Health Administration settings. Guided by the Systems Engineering Initiative for Patient Safety, we conducted focus groups and interviews to capture barriers and facilitators to daily CHG bathing. We measured compliance using observations and skin CHG concentrations. RESULTS Barriers to daily CHG include time, concern of increasing antibiotic resistance, workflow and product concerns. Facilitators include engagement of champions and unit shared responsibility. We found shortfalls in patient education, hand hygiene and CHG use on tubes and drains. CHG skin concentration levels were highest among patients from spinal cord injury units. These units applied antiseptic using 2% CHG impregnated wipes vs 4% CHG solution/soap. DISCUSSION Non-ICUs implementing CHG bathing must consider human factors and work system barriers to ensure uptake and sustained practice change. CONCLUSIONS Well-planned rollouts and a unit culture promoting shared responsibility are key to compliance with daily CHG bathing. Successful implementation requires attention to staff education and measurement of compliance.
Collapse
|
13
|
Bruce C, Harrison P, Giammattei C, Desai SN, Sol JR, Jones S, Schwartz R. Evaluating Patient-Centered Mobile Health Technologies: Definitions, Methodologies, and Outcomes. JMIR Mhealth Uhealth 2020; 8:e17577. [PMID: 33174846 PMCID: PMC7688390 DOI: 10.2196/17577] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 04/11/2020] [Accepted: 10/23/2020] [Indexed: 01/20/2023] Open
Abstract
Several recently published studies and consensus statements have demonstrated that there is only modest (and in many cases, low-quality) evidence that mobile health (mHealth) can improve patient clinical outcomes such as the length of stay or reduction of readmissions. There is also uncertainty as to whether mHealth can improve patient-centered outcomes such as patient engagement or patient satisfaction. One principal challenge behind the “effectiveness” research in this field is a lack of common understanding about what it means to be effective in the digital space (ie, what should constitute a relevant outcome and how best to measure it). In this viewpoint, we call for interdisciplinary, conceptual clarity on the definitions, methodologies, and patient-centered outcomes frequently used in mHealth research. To formulate our recommendations, we used a snowballing approach to identify relevant definitions, outcomes, and methodologies related to mHealth. To begin, we drew heavily upon previously published detailed frameworks that enumerate definitions and measurements of engagement. We built upon these frameworks by extracting other relevant measures of patient-centered care, such as patient satisfaction, patient experience, and patient activation. We describe several definitional inconsistencies for key constructs in the mHealth literature. In an effort to achieve clarity, we tease apart several patient-centered care outcomes, and outline methodologies appropriate to measure each of these patient-care outcomes. By creating a common pathway linking definitions with outcomes and methodologies, we provide a possible interdisciplinary approach to evaluating mHealth technologies. With the broader goal of creating an interdisciplinary approach, we also provide several recommendations that we believe can advance mHealth research and implementation.
Collapse
Affiliation(s)
- Courtenay Bruce
- System Quality & Patient Safety, Houston Methodist System, Houston, TX, United States
| | - Patricia Harrison
- System Quality & Patient Safety, Houston Methodist System, Houston, TX, United States
| | | | - Shetal-Nicholas Desai
- Center for Innovation, Houston Methodist Hospital, Houston, TX, United States.,Information Technology Division, Houston Methodist Hospital, Houston, TX, United States
| | - Joshua R Sol
- Center for Innovation, Houston Methodist Hospital, Houston, TX, United States.,Information Technology Division, Houston Methodist Hospital, Houston, TX, United States
| | - Stephen Jones
- Center for Outcomes Research, Houston Methodist Research Institute, Houston, TX, United States.,Department of Surgery, Houston Methodist Hospital, Houston, TX, United States
| | - Roberta Schwartz
- Center for Innovation, Houston Methodist Hospital, Houston, TX, United States
| |
Collapse
|
14
|
In-Hospital Patient Safety Events, Healthcare Costs and Utilization: An Analysis from the Incident Reporting System in an Academic Medical Center. Healthcare (Basel) 2020; 8:healthcare8040388. [PMID: 33036424 PMCID: PMC7711548 DOI: 10.3390/healthcare8040388] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/02/2020] [Accepted: 10/06/2020] [Indexed: 11/29/2022] Open
Abstract
The possible association of patient safety events (PSEs) with the costs and utilization remains a concern. In this retrospective analysis, we investigated adult hospitalizations at a medical center between 2010 and 2015 with or without reported PSEs. Administrative and claims data were analyzed to compare the costs and length of stay (LOS) between cases with and without PSEs of the three most common categories during the first 14 days of hospitalization. Two models, including linear regression and propensity score-matched comparison, were performed for each reference day group of hospitalizations. Of 14,181 PSEs from 424,635 hospitalizations, 69.8% were near miss or no-harm events. Costs and LOS were similar between fall cases and controls in all of the 14 reference days. In contrast, for cases of tube and line events and controls, there were consistent differences in costs and LOS in the majority of the reference days (86% and 57%, respectively). Consistent differences were less frequently seen for medication events and control events (36% and 43%, respectively). Our study approach of comparing cases with PSEs and those without any PSE showed significant differences in costs and LOS for tube and line events, and medication events. No difference in cost or LOS was found regarding fall events. Further studies exploring adjustments for event risks and harm-oriented analysis are warranted.
Collapse
|
15
|
Patient Safety in Primary Care: Conceptual Meanings to the Health Care Team and Patients. J Am Board Fam Med 2020; 33:754-764. [PMID: 32989070 PMCID: PMC7938708 DOI: 10.3122/jabfm.2020.05.200042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 04/14/2020] [Accepted: 04/14/2020] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Patient safety in primary care is an emerging priority, and experts have highlighted medications, diagnoses, transitions, referrals, and testing as key safety domains. This study aimed to (1) describe how frontline clinicians, administrators, and staff conceptualize patient safety in primary care; and (2) compare and contrast these conceptual meanings from the patient's perspective. METHODS We conducted interviews with 101 frontline clinicians, administrators and staff, and focus groups with 65 adult patients at 10 patient-centered medical homes. We used thematic analysis to approach coding. RESULTS Findings indicate that frontline personnel conceptualized patient safety more in terms of work functions, which reflect the grouping of tasks or responsibilities to guide how care is being delivered. Frontline personnel and patients conceptualized patient safety in largely consistent ways. DISCUSSION Function-based conceptualizations of patient safety in primary care may better reflect frontline personnel and patients' experiences than domain-based conceptualizations, which are favored by experts.
Collapse
|
16
|
Implementing daily chlorhexidine gluconate treatment for the prevention of healthcare-associated infections in non-intensive care settings: A multiple case analysis. PLoS One 2020; 15:e0232062. [PMID: 32330165 PMCID: PMC7182260 DOI: 10.1371/journal.pone.0232062] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 04/06/2020] [Indexed: 11/25/2022] Open
Abstract
Introduction Daily bathing with chlorhexidine gluconate (CHG) in hospitalized patients reduces healthcare-associated bloodstream infections and colonization by multidrug-resistant organisms. Achieving compliance with bathing protocols is challenging. This non-intensive care unit multicenter project evaluated the impact of organizational context on implementation of CHG and assessed compliance with and healthcare workers’ perceptions of the intervention. Materials and methods This was a multiple case study based on the SEIPS (Systems Engineering Initiative for Patient Safety) model of work system and patient safety. The four sites included an adult cardiovascular unit in a community hospital, a medical-surgical unit in an academic teaching pediatric hospital, an adult medical-surgical acute care unit and an adult neuroscience acute care unit in another academic teaching hospital. Complementary data collection methods included focus groups and interviews with healthcare workers (HCWs) and leaders, and direct observations of the CHG treatment process and skin swabs. Results We collected 389 bathing observations and 110 skin swabs, conducted four focus groups with frontline workers and interviewed leaders. We found variation across cases in CHG compliance, skin swab data and implementation practices. Mean compliance with the bathing process ranged from 64% to 83%. Low detectable CHG on the skin was related to immediate rinsing of CHG from the skin. Variation in the implementation of CHG treatments was related to differences in organizational education and training practices, feedback and monitoring practices, patient education or information about CHG treatments, patient preferences and general unit patient population differences. Conclusion Organizations planning to implement CHG treatments in non-ICU settings should ensure organizational readiness and buy-in and consider delivering systematic and ongoing training. Clear and systematic implementation policies across patients and units may help reduce potential confusion about treatment practices and variation across HCWs. Patient populations and unit factors need to be carefully considered and procedures developed to manage unique challenges.
Collapse
|
17
|
Scrimshire AB, Booth A, Fairhurst C, Reed M, Tadd W, Laverty A, Corbacho B, Torgerson D, McDaid C. Scaling up Quality Improvement for Surgical Teams (QIST) - avoiding surgical site infection and anaemia at the time of surgery: protocol for a cluster randomised controlled trial. Trials 2020; 21:234. [PMID: 32111244 PMCID: PMC7048022 DOI: 10.1186/s13063-020-4152-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 02/06/2020] [Indexed: 11/21/2022] Open
Abstract
Background Measures shown to improve outcomes for patients often fail to be adopted into routine practice in the NHS. The Institute for Health Improvement Breakthrough Series Collaborative (BSC) model is designed to support implementation at scale. This trial aims to assess the effectiveness and cost-effectiveness of quality improvement collaboratives (QICs) based on the BSC method for introducing service improvements at scale in the NHS. Methods Forty Trusts will be randomised (1:1) to introduce one of two protocols already shown to improve outcomes in patients undergoing elective total hip and knee replacement surgery. The intervention is improvement collaboratives based on the BSC model, a learning system that brings together a large number of teams to seek improvement focussed on a proven intervention. Collaboratives aim to deliver at scale, maximise local engagement and leadership and are designed to build capacity, enable learning and prepare for sustainability. Collaboratives involve Learning Sessions, Action Periods, and a summative congress. Trusts will be supported to introduce either: decolonisation for Methicillin Sensitive Staphylococcus aureus (MSSA) to reduce post-operative infection (QIST: Infection), or an anaemia optimisation programme to reduce peri-operative blood transfusions (QIST: Anaemia). Trusts will continue with their usual practice for whichever protocol they are not introducing. Anonymised data related to both infection and anaemia outcomes for patients undergoing hip or knee arthroplasty at all sites will mean that the two groups act as controls for each other. The primary outcome for the QIST: Infection collaborative is deep MSSA surgical site infection within 90 days of surgery, and for the QIST: Anaemia collaborative is blood transfusion within 7 days of surgery. Patient-level secondary outcomes include length of hospital stay and readmission, which will also inform the economic costings. Qualitative interviews will evaluate the support provided to teams. Discussion The scale of this trial brings considerable challenges and potential barriers to delivery. Anticipated challenges relate to recruiting and sustaining up to 40 organisations, each with its own culture and context. This complex project with multiple stakeholders across a large geographical area will be managed by experienced senior-level project leaders with a proven track record in advanced project management. The team should ensure effective project governance and communications. Trial registration ISRCTN, ISRCTN11085475. Prospectively registered on 15 February 2018.
Collapse
Affiliation(s)
- Ashley B Scrimshire
- Department of Health Sciences, University of York, Heslington, York, YO10 5DD, UK. .,Northumbria Healthcare NHS Foundation Trust, Woodhorn Lane, Ashington, NE63 9JJ, UK.
| | - Alison Booth
- Department of Health Sciences, University of York, Heslington, York, YO10 5DD, UK
| | - Caroline Fairhurst
- Department of Health Sciences, University of York, Heslington, York, YO10 5DD, UK
| | - Mike Reed
- Northumbria Healthcare NHS Foundation Trust, Woodhorn Lane, Ashington, NE63 9JJ, UK
| | | | - Annie Laverty
- Northumbria Healthcare NHS Foundation Trust, Woodhorn Lane, Ashington, NE63 9JJ, UK
| | - Belen Corbacho
- Department of Health Sciences, University of York, Heslington, York, YO10 5DD, UK
| | - David Torgerson
- Department of Health Sciences, University of York, Heslington, York, YO10 5DD, UK
| | - Catriona McDaid
- Department of Health Sciences, University of York, Heslington, York, YO10 5DD, UK
| |
Collapse
|
18
|
Ravishankar A, Turetsky Y, Novotny S, Allen T, Farah RS. Implementing Laser Safety Standards in the Outpatient Academic Dermatology Clinic: A Quality Improvement Based Study. Lasers Surg Med 2019; 52:485-487. [DOI: 10.1002/lsm.23174] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2019] [Indexed: 11/07/2022]
Affiliation(s)
- Adarsh Ravishankar
- University of Minnesota Medical School420 Delaware St SE Minneapolis Minnesota 55455
| | - Yelizaveta Turetsky
- Department of DermatologyUniversity of Minnesota Health500 SE Harvard St Minneapolis Minnesota 55455
| | - Shelley Novotny
- Department of DermatologyUniversity of Minnesota Health500 SE Harvard St Minneapolis Minnesota 55455
| | - Taryn Allen
- Department of DermatologyUniversity of Minnesota Health500 SE Harvard St Minneapolis Minnesota 55455
| | - Ronda S. Farah
- University of Minnesota Medical School420 Delaware St SE Minneapolis Minnesota 55455
- Department of DermatologyUniversity of Minnesota Health500 SE Harvard St Minneapolis Minnesota 55455
- Department of DermatologyUniversity of MinnesotaMinneapolis Minnesota
| |
Collapse
|
19
|
Adelman JS, Applebaum JR, Southern WN. Limiting the Number of Open Records in an Electronic Health Record-Reply. JAMA 2019; 322:1314-1315. [PMID: 31573633 DOI: 10.1001/jama.2019.11501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Jason S Adelman
- Division of General Medicine, Columbia University Irving Medical Center, New York, New York
| | - Jo R Applebaum
- Department of Quality and Patient Safety, New York-Presbyterian Hospital, New York
| | - William N Southern
- Division of Hospital Medicine, Albert Einstein College of Medicine, Bronx, New York
| |
Collapse
|
20
|
Turley CB, Brittingham J, Moonan A, Davis D, Chakraborty H. Statewide Longitudinal Progression of the Whole-Patient Measure of Safety in South Carolina. J Healthc Qual 2019; 40:256-264. [PMID: 28933708 PMCID: PMC6133206 DOI: 10.1097/jhq.0000000000000092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Meaningful improvement in patient safety encompasses a vast number of quality metrics, but a single measure to represent the overall level of safety is challenging to produce. Recently, Perla et al. established the Whole-Person Measure of Safety (WPMoS) to reflect the concept of global risk assessment at the patient level. We evaluated the WPMoS across an entire state to understand the impact of urban/rural setting, academic status, and hospital size on patient safety outcomes. The population included all South Carolina (SC) inpatient discharges from January 1, 2008, through to December 31, 2013, and was evaluated using established definitions of highly undesirable events (HUEs). Over the study period, the proportion of hospital discharges with at least one HUE significantly decreased from 9.7% to 8.8%, including significant reductions in nine of the 14 HUEs. Academic, large, and urban hospitals had a significantly lower proportion of hospital discharges with at least one HUE in 2008, but only urban hospitals remained significantly lower by 2013. Results indicate that there has been a decrease in harm events captured through administrative coded data over this 6-year period. A composite measure, such as the WPMoS, is necessary for hospitals to evaluate their progress toward reducing preventable harm.
Collapse
|
21
|
Implementation of a Clostridioides difficile prevention bundle: Understanding common, unique, and conflicting work system barriers and facilitators for subprocess design. Infect Control Hosp Epidemiol 2019; 40:880-888. [PMID: 31190669 DOI: 10.1017/ice.2019.150] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Clostridioides difficile (C. difficile) poses a major challenge to the healthcare system. We assessed factors that should be considered when designing subprocesses of a C. difficile infection (CDI) prevention bundle. DESIGN Phenomenological qualitative study. METHODS We conducted 3 focus groups of environmental services (EVS) staff, physicians, and nurses to assess their perspectives on a CDI prevention bundle. We used the Systems Engineering Initiative for Patient Safety (SEIPS) model to examine 5 subprocesses of the CDI bundle: diagnostic testing, empiric isolation, contact isolation, hand hygiene, and environmental disinfection. We coded transcripts to the 5 SEIPS elements and ensured scientific rigor. We sought to determine common, unique, and conflicting factors across stakeholder groups and subprocesses of the CDI bundle. RESULTS Each focus group lasted 1.5 hours on average. Common work-system barriers included inconsistencies in knowledge and practice of CDI management procedures; increased workload; poor setup of aspects of the physical environment (eg, inconvenient location of sinks); and inconsistencies in CDI documentation. Unique barriers and facilitators were related to specific activities performed by the stakeholder group. For instance, algorithmic approaches used by physicians facilitated timely diagnosis of CDI. Conflicting barriers or facilitators were related to opposing objectives; for example, clinicians needed rapid placement of a patient in a room while EVS staff needed time to disinfect the room. CONCLUSIONS A systems engineering approach can help to holistically identify factors that influence successful implementation of subprocesses of infection prevention bundles.
Collapse
|
22
|
Aggarwal MV, Jarrell AS, Gilmore VT, Aboagye JK, Haut ER, Hobson DB, Lau BD, Kickler T, Kraus PS, Shaffer DL, Shermock KM, Streiff MB, Zheng G, Kruer RM. Anti-Xa activity by weight in critically ill patients receiving unfractionated heparin for venous thromboembolism prophylaxis. J Crit Care 2019; 52:180-185. [PMID: 31078999 DOI: 10.1016/j.jcrc.2019.04.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 04/25/2019] [Accepted: 04/26/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE This study compared anti-Xa activity in critically ill patients receiving UFH for VTE prophylaxis between two weight groups (<100 kg vs ≥100 kg). METHODS This prospective, observational study included critically ill patients on UFH 5000 or 7500 units every 8 h. A peak and trough anti-Xa activity assay was ordered for each patient at steady state. Goal peak anti-Xa activity was 0.1-0.3 units/mL. RESULTS From March 2017 to June 2018, 75 patients were enrolled with 44 in the <100 kg group and 31 in the ≥100 kg group. There was no significant difference in the percentage of patients with peak anti-Xa activity within goal range between patients <100 kg and ≥ 100 kg (55.3% vs 35.7%, p = 0.12). The odds ratio for achieving peak anti-Xa activity within goal range as weight-based dose increased was 1.03 (95% CI 0.99-1.07). No differences were found in trough anti-Xa activity, VTE, bleeding, length of stay, or death. CONCLUSIONS Though only one-third of patients ≥100 kg had peak anti-Xa activity within goal range, no significant difference was found between the weight groups. Additional prospective studies with adequate sample sizes are warranted to further investigate appropriate weight-based dosing of UFH in critically ill patients.
Collapse
Affiliation(s)
| | | | - Vi T Gilmore
- Department of Pharmacy, The Johns Hopkins Hospital, USA
| | - Jonathan K Aboagye
- Department of Surgery, The Johns Hopkins University School of Medicine, USA
| | - Elliott R Haut
- Department of Surgery, The Johns Hopkins University School of Medicine, USA; Armstrong Institute for Patient Safety and Quality, USA; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, USA; Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, USA; Department of Emergency Medicine, The Johns Hopkins University School of Medicine, USA
| | - Deborah B Hobson
- Department of Surgery, The Johns Hopkins University School of Medicine, USA; Armstrong Institute for Patient Safety and Quality, USA
| | - Brandyn D Lau
- Armstrong Institute for Patient Safety and Quality, USA; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, USA; Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, USA; Division of Health Sciences Informatics, The Johns Hopkins University School of Medicine, USA
| | - Thomas Kickler
- Department of Pathology, The Johns Hopkins University School of Medicine, USA
| | - Peggy S Kraus
- Department of Pharmacy, The Johns Hopkins Hospital, USA
| | - Dauryne L Shaffer
- Department of Surgery, The Johns Hopkins University School of Medicine, USA
| | | | - Michael B Streiff
- Armstrong Institute for Patient Safety and Quality, USA; Division of Hematology, Department of Medicine, The Johns Hopkins University School of Medicine, USA
| | - Gang Zheng
- Department of Pathology, The Johns Hopkins University School of Medicine, USA
| | | |
Collapse
|
23
|
Portela MC, Lima SML, da Costa Reis LG, Martins M, Aveling EL. Challenges to the improvement of obstetric care in maternity hospitals of a large Brazilian city: an exploratory qualitative approach on contextual issues. BMC Pregnancy Childbirth 2018; 18:459. [PMID: 30477475 PMCID: PMC6258487 DOI: 10.1186/s12884-018-2088-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 11/14/2018] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Maternal morbidity and mortality are still serious public health concerns in Brazil, and access to quality obstetric care is one critical point of this problem. Despite efforts, obstetric care quality problems and sub-optimal/poor outcomes persist. The study aimed to identify contextual elements that would potentially affect the implementation of an obstetric care quality improvement intervention. METHODS A qualitative study was conducted in three public maternity hospitals of a large Brazilian city, with high annual volume of births and buy-in from high-level managers. Individual interviews with doctors and nurses were conducted from July to October 2015. Semi-structured interviews sought to explore teamwork, coordination and communication, and leadership, being open to capture other contextual elements that could emerge. Interviews were recorded and transcribed, and the categories of analysis were identified and updated based on the constant comparative method. RESULTS Twenty-seven interviews were carried out. Extra-organizational context concerning the dependence of the maternity hospitals on primary care units, responsible for antenatal care, and on other healthcare organizations' services emerged from interviews, but the main findings of the study centered on intra-organizational context with potential to affect healthcare quality and actions for its improvement, including material resources, work organization design, teamwork, coordination and communication, professional responsibility vis-à-vis the patient, and leadership. A major issue was the divergence of physicians' and nurses' perspectives on care quality, which in turn negatively affected their capacity to work together. CONCLUSION Overall, the findings suggest that care on the maternity hospitals was fragmented and lacked continuity, putting at risk the quality. Redesigning work organization, promoting conditions for multi-professional teamwork, better communication and coordination, improving more systemic accountability/lines of authority, and investing in team members' technical competence, and fitness of organizational structures and processes are all imbricated actions that may contribute to obstetric care quality improvement.
Collapse
Affiliation(s)
- Margareth Crisóstomo Portela
- Department of Health Administration and Planning, National School of Public Health, Oswaldo Cruz Foundation, Rio de Janeiro, RJ Brazil
| | - Sheyla Maria Lemos Lima
- Department of Health Administration and Planning, National School of Public Health, Oswaldo Cruz Foundation, Rio de Janeiro, RJ Brazil
| | - Lenice Gnocchi da Costa Reis
- Department of Health Administration and Planning, National School of Public Health, Oswaldo Cruz Foundation, Rio de Janeiro, RJ Brazil
| | - Mônica Martins
- Department of Health Administration and Planning, National School of Public Health, Oswaldo Cruz Foundation, Rio de Janeiro, RJ Brazil
| | - Emma-Louise Aveling
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA USA
- The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge, UK
| |
Collapse
|
24
|
Rattray NA, Ebright P, Flanagan ME, Militello LG, Barach P, Franks Z, Rehman SU, Gordon HS, Frankel RM. Content counts, but context makes the difference in developing expertise: a qualitative study of how residents learn end of shift handoffs. BMC MEDICAL EDUCATION 2018; 18:249. [PMID: 30390668 PMCID: PMC6215683 DOI: 10.1186/s12909-018-1350-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 10/15/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND Handoff education is both formal and informal and varies widely across medical school and residency training programs. Despite many efforts to improve clinical handoffs, little evidence has shown meaningful improvement. The objective of this study was to identify residents' perspectives and develop a deeper understanding on the necessary training to conduct safe and effective patient handoffs. METHODS A qualitative study focused on the analysis of cognitive task interviews targeting end-of-shift handoff experiences with 35 residents from three geographically dispersed VA facilities. The interview data were analyzed using an iterative, consensus-based team approach. Researchers discussed and agreed on code definitions and corresponding case examples. Grounded theory was used to analyze the transcripts. RESULTS Although some residents report receiving formal training in conducting handoffs (e.g., medical school coursework, resident boot camp/workshops, and handoff debriefing), many residents reported that they were only partially prepared for enacting them as interns. Experiential, practice-based learning (i.e., giving handoffs, covering night shift to match common issues to handoff content) was identified as the most suited and beneficial for delivering effective handoff training. Six skills were described as critical to learning effective handoffs: identifying pertinent information, providing anticipatory guidance, applying acquired clinical knowledge, being concise, incorporating delivery strategies, and appreciating the styles/preferences of handoff recipients. CONCLUSIONS Residents identified the immersive performance and the experience of covering night shifts as the most important aspects of learning to execute effective handoffs. Formal education alone can miss the critical role of real-time sense-making throughout the process of handing off from one trainee to another. Interventions targeting senior resident mentoring and night shift could positively influence the cognitive and performance capacity for safe, effective handoffs.
Collapse
Affiliation(s)
- Nicholas A. Rattray
- VA HSR&D Center for Health Information and Communication, Roudebush VAMC, Indianapolis, USA
- Department of Anthropology, Indiana University-Purdue University Indianapolis, Indianapolis, USA
- Regenstrief Institute, Inc., Indianapolis, USA
| | | | - Mindy E. Flanagan
- VA HSR&D Center for Health Information and Communication, Roudebush VAMC, Indianapolis, USA
| | | | - Paul Barach
- Wayne State University School of Medicine, Detroit, USA
| | - Zamal Franks
- VA HSR&D Center for Health Information and Communication, Roudebush VAMC, Indianapolis, USA
| | - Shakaib U. Rehman
- Phoenix VA Healthcare Systems, Phoenix, USA
- University of Arizona College of Medicine-Phoenix, Phoenix, USA
| | - Howard S. Gordon
- VA HSR&D Center of Innovation for Complex Chronic Healthcare, Jesse Brown VAMC, Chicago, USA
- University of Illinois at Chicago, Chicago, USA
| | - Richard M. Frankel
- VA HSR&D Center for Health Information and Communication, Roudebush VAMC, Indianapolis, USA
- Regenstrief Institute, Inc., Indianapolis, USA
- Indiana University School of Medicine, Indianapolis, USA
| |
Collapse
|
25
|
Cheung YY, Riblet NBV, Osunkoya TO. Use of Iterative Cycles in Quality Improvement Projects in Imaging: A Systematic Review. J Am Coll Radiol 2018; 15:1587-1602. [PMID: 30181090 DOI: 10.1016/j.jacr.2018.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 06/05/2018] [Accepted: 06/08/2018] [Indexed: 01/07/2023]
Abstract
PURPOSE Studies suggest that quality improvement (QI) projects in health care lack scientific rigor, but the actual frequency of use of proven scientific QI methodology is unknown. The purposes of this study are to (1) conduct a systematic review of QI projects in radiology journals on the frequency of use of iterative cycles, a marker of proven QI methodology, and (2) assess association of the use of iterative cycles with characteristics of these projects. MATERIALS AND METHODS We searched English-language radiology journals on MEDLINE between 2008 and 2015 for published QI studies. Three reviewers appraised studies and extracted data. Use of iterative cycles was identified, and results were summarized qualitatively. χ2 Analysis evaluated associations of iterative cycles with other data elements. RESULTS Of 3,134 potentially eligible citations, 44 studies met inclusion criteria. Only 46% of these used iterative cycles to refine intervention. Use of iterative cycles were associated with projects designed to improve process, QI expert support, reporting of unintended effect of intervention, and explicitly stated use of iterative cycles. General lack of scientific rigor was represented by failure to report baseline data (9%), describe unintended effects (66%), and discuss limitations (36%). CONCLUSIONS Our systematic review found fewer than half of the QI projects in radiology journals used iterative cycles to refine intervention, a scientific strategy central to many proven improvement methodologies. Use of iterative approach was associated with projects designed to improve processes, QI expert support, report of unintended effect, and explicitly stated use of iterative cycles.
Collapse
Affiliation(s)
- Yvonne Y Cheung
- Department of Radiology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire.
| | - Natalie B V Riblet
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire
| | - Tomiwa O Osunkoya
- Department of Radiology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| |
Collapse
|
26
|
Monfort E, Gandit M, Poulet C, Quillion-Dupré L, Boudin B, Couturier P. Perception of domestic risks among carers for dependent older persons. Psychogeriatrics 2018; 18:371-378. [PMID: 29987862 DOI: 10.1111/psyg.12331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 11/27/2017] [Accepted: 02/03/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Despite growing interest for home care, little evidence exists on the perception of domestic risk among carers for dependent older persons. This study aims to characterize the risks to which carers of aging dependent individuals are exposed, and to determine whether these risk dimensions are predictive for effective support, for burden, and for psychological distress. METHODS Seventy care partners were questioned about the risk situations identified at the homes of the old people they care for, about the burden they felt in their role, and about their feelings of psychological distress. Securing was evaluated by means of sensibility measures, and overprotection was evaluated by means of specificity measures. RESULTS Risk rates were high for loneliness of the old people, wandering, burns, and unsatisfactory health monitoring. There was very little overlap between identification of the risks and implementation of solutions by the caregiver, except for the risks that involved heat. The distinction between accurate securing and overprotection is especially important, because the burden of care partners was linked to uncontrolled domestic risks. CONCLUSION Typologies of reactions to risk, characterized by a signal detection approach, could contribute to a better understanding of the situations experienced by care partners, especially situations of neglect and of overprotection.
Collapse
Affiliation(s)
- Emmanuel Monfort
- Grenoble Psychology Laboratory (LIP/PC2S), University Grenoble Alpes, Grenoble Cedex, France
| | - Marc Gandit
- Grenoble Psychology Laboratory (LIP/PC2S), University Grenoble Alpes, Grenoble Cedex, France
| | - Caroline Poulet
- Grenoble Psychology Laboratory (LIP/PC2S), University Grenoble Alpes, Grenoble Cedex, France
| | - Lisa Quillion-Dupré
- Autonomy Gerontology E-health Imagery and Society Laboratory (AGEIS), University of Grenoble Alpes, Grenoble Cedex, France
| | - Bertrand Boudin
- Grenoble Psychology Laboratory (LIP/PC2S), University Grenoble Alpes, Grenoble Cedex, France
| | - Pascal Couturier
- Department of Geriatric Medicine - ThEMAS TIMC-IMAG, Grenoble Alpes University Hospital, Grenoble Cedex, France
| |
Collapse
|
27
|
Clack L, Zingg W, Saint S, Casillas A, Touveneau S, da Liberdade Jantarada F, Willi U, van der Kooi T, Damschroder LJ, Forman JH, Harrod M, Krein S, Pittet D, Sax H. Implementing infection prevention practices across European hospitals: an in-depth qualitative assessment. BMJ Qual Saf 2018; 27:771-780. [PMID: 29950324 PMCID: PMC6166596 DOI: 10.1136/bmjqs-2017-007675] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 05/08/2018] [Accepted: 05/13/2018] [Indexed: 11/18/2022]
Abstract
Objective The Prevention of Hospital Infections by Intervention and Training (PROHIBIT) project included a cluster-randomised, stepped wedge, controlled study to evaluate multiple strategies to prevent catheter-related bloodstream infection. We report an in-depth investigation of the main barriers, facilitators and contextual factors relevant to successfully implementing these strategies in European acute care hospitals. Methods Qualitative comparative case study in 6 of the 14 European PROHIBIT hospitals. Data were collected through interviews with key stakeholders and ethnographic observations conducted during 2-day site visits, before and 1 year into the PROHIBIT intervention. Qualitative measures of implementation success included intervention fidelity, adaptation to local context and satisfaction with the intervention programme. Results Three meta-themes emerged related to implementation success: ‘implementation agendas’, ‘resources’ and ‘boundary-spanning’. Hospitals established unique implementation agendas that, while not always aligned with the project goals, shaped subsequent actions. Successful implementation required having sufficient human and material resources and dedicated change agents who helped make the intervention an institutional priority. The salary provided for a dedicated study nurse was a key facilitator. Personal commitment of influential individuals and boundary spanners helped overcome resource restrictions and intrainstitutional segregation. Conclusion This qualitative study revealed patterns across cases that were associated with successful implementation. Consideration of the intervention–context relation was indispensable to understanding the observed outcomes.
Collapse
Affiliation(s)
- Lauren Clack
- Division of Infectious Diseases and Hospital Epidemiology, University of Zurich, University Hospital of Zurich, Zurich, Switzerland.,Infection Control Programme, University of Geneva Hospitals, Geneva, Switzerland
| | - Walter Zingg
- Infection Control Programme, University of Geneva Hospitals, Geneva, Switzerland
| | - Sanjay Saint
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.,Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Alejandra Casillas
- Division of General Internal Medicine and Health Services Research, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Sylvie Touveneau
- Infection Control Programme, University of Geneva Hospitals, Geneva, Switzerland
| | | | - Ursina Willi
- Division of Infectious Diseases and Hospital Epidemiology, University of Zurich, University Hospital of Zurich, Zurich, Switzerland
| | - Tjallie van der Kooi
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
| | - Laura J Damschroder
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Jane H Forman
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Molly Harrod
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Sarah Krein
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.,Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Didier Pittet
- Infection Control Programme, University of Geneva Hospitals, Geneva, Switzerland
| | - Hugo Sax
- Division of Infectious Diseases and Hospital Epidemiology, University of Zurich, University Hospital of Zurich, Zurich, Switzerland.,Infection Control Programme, University of Geneva Hospitals, Geneva, Switzerland
| | | |
Collapse
|
28
|
Lavallée JF, Gray TA, Dumville J, Cullum N. Barriers and facilitators to preventing pressure ulcers in nursing home residents: A qualitative analysis informed by the Theoretical Domains Framework. Int J Nurs Stud 2018; 82:79-89. [DOI: 10.1016/j.ijnurstu.2017.12.015] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 11/07/2017] [Accepted: 12/30/2017] [Indexed: 11/25/2022]
|
29
|
Neta G, Brownson RC, Chambers DA. Opportunities for Epidemiologists in Implementation Science: A Primer. Am J Epidemiol 2018; 187:899-910. [PMID: 29036569 DOI: 10.1093/aje/kwx323] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 09/21/2017] [Indexed: 12/29/2022] Open
Abstract
The field of epidemiology has been defined as the study of the spread and control of disease. However, epidemiology frequently focuses on studies of etiology and distribution of disease at the cost of understanding the best ways to control disease. Moreover, only a small fraction of scientific discoveries are translated into public health practice, and the process from discovery to translation is exceedingly slow. Given the importance of translational science, the future of epidemiologic training should include competency in implementation science, whose goal is to rapidly move evidence into practice. Our purpose in this paper is to provide epidemiologists with a primer in implementation science, which includes dissemination research and implementation research as defined by the National Institutes of Health. We describe the basic principles of implementation science, highlight key components for conducting research, provide examples of implementation studies that encompass epidemiology, and offer resources and opportunities for continued learning. There is a clear need for greater speed, relevance, and application of evidence into practice, programs, and policies and an opportunity to enable epidemiologists to conduct research that not only will inform practitioners and policy-makers of risk but also will enhance the likelihood that evidence will be implemented.
Collapse
Affiliation(s)
- Gila Neta
- Implementation Science, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland
| | - Ross C Brownson
- Prevention Research Center in St. Louis, Brown School, Washington University in St. Louis, St. Louis, Missouri
- Division of Public Health Sciences, Department of Surgery, School of Medicine, Washington University in St. Louis, St. Louis, Missouri
- Alvin J. Siteman Cancer Center, School of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | - David A Chambers
- Implementation Science, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland
| |
Collapse
|
30
|
Wiig S, Ree E, Johannessen T, Strømme T, Storm M, Aase I, Ullebust B, Holen-Rabbersvik E, Hurup Thomsen L, Sandvik Pedersen AT, van de Bovenkamp H, Bal R, Aase K. Improving quality and safety in nursing homes and home care: the study protocol of a mixed-methods research design to implement a leadership intervention. BMJ Open 2018; 8:e020933. [PMID: 29599394 PMCID: PMC5875614 DOI: 10.1136/bmjopen-2017-020933] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 02/07/2018] [Accepted: 02/20/2018] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Nursing homes and home care face challenges across different countries as people are living longer, often with chronic conditions. There is a lack of knowledge regarding implementation and impact of quality and safety interventions as most research evidence so far is generated in hospitals. Additionally, there is a lack of effective leadership tools for quality and safety improvement work in this context. METHODS AND ANALYSIS The aim of the 'Improving Quality and Safety in Primary Care-Implementing a Leadership Intervention in Nursing Homes and Homecare' (SAFE-LEAD) study is to develop and evaluate a research-based leadership guide for managers to increase quality and safety competence. The project applies a mixed-methods design and explores the implications of the leadership guide on managers' and staffs' knowledge, attitudes and practices. Four nursing homes and four home care services from different Norwegian municipalities will participate in the intervention. Surveys, process evaluation (interviews, observations) and document analyses will be conducted to evaluate the implementation and impact of the leadership intervention. A comparative study of Norway and the Netherlands will establish knowledge of the context dependency of the intervention. ETHICS AND DISSEMINATION The study is approved by the Norwegian Centre for Research Data (2017/52324 and 54855). The results will be disseminated through scientific articles, two PhD dissertations, an anthology, presentations at national and international conferences, and in social media, newsletters and in the press. The results will generate knowledge to inform leadership practices in nursing homes and home care. Moreover, the study will build new theory on leadership interventions and the role of contextual factors in nursing homes and home care.
Collapse
Affiliation(s)
- Siri Wiig
- SHARE- Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Eline Ree
- SHARE- Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Terese Johannessen
- SHARE- Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Torunn Strømme
- SHARE- Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Marianne Storm
- SHARE- Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Ingunn Aase
- SHARE- Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Berit Ullebust
- Center for Developing Institutional and Home Care Services Sogn and Fjordane, Førde, Norway
| | - Elisabeth Holen-Rabbersvik
- SHARE- Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
- Department of Health and Nursing Sciences, University of Agder, Kristiansand, Norway
- Songdalen Municipality, Songdalen, Norway
| | - Line Hurup Thomsen
- Center for Developing Institutional and Home Care Services Rogaland, Stavanger, Norway
| | | | | | - Roland Bal
- School of Health Policy & Management, Erasmus University, Rotterdam, The Netherlands
| | - Karina Aase
- SHARE- Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| |
Collapse
|
31
|
What is the impact of professional nursing on patients’ outcomes globally? An overview of research evidence. Int J Nurs Stud 2018; 78:76-83. [DOI: 10.1016/j.ijnurstu.2017.10.009] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Accepted: 10/17/2017] [Indexed: 11/20/2022]
|
32
|
Dreischulte T, Grant A, Hapca A, Guthrie B. Process evaluation of the Data-driven Quality Improvement in Primary Care (DQIP) trial: quantitative examination of variation between practices in recruitment, implementation and effectiveness. BMJ Open 2018; 8:e017133. [PMID: 29306877 PMCID: PMC5780698 DOI: 10.1136/bmjopen-2017-017133] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES The cluster randomised trial of the Data-driven Quality Improvement in Primary Care (DQIP) intervention showed that education, informatics and financial incentives for general medical practices to review patients with ongoing high-risk prescribing of non-steroidal anti-inflammatory drugs and antiplatelets reduced the primary end point of high-risk prescribing by 37%, where both ongoing and new high-risk prescribing were significantly reduced. This quantitative process evaluation examined practice factors associated with (1) participation in the DQIP trial, (2) review activity (extent and nature of documented reviews) and (3) practice level effectiveness (relative reductions in the primary end point). SETTING/PARTICIPANTS Invited practices recruited (n=33) and not recruited (n=32) to the DQIP trial in Scotland, UK. OUTCOME MEASURES (1) Characteristics of recruited versus non-recruited practices. Associations of (2) practice characteristics and 'adoption' (self-reported implementation work done by practices) with documented review activity and (3) of practice characteristics, DQIP adoption and review activity with effectiveness. RESULTS (1) Recruited practices had lower performance in the quality and outcomes framework than those declining participation. (2) Not being an approved general practitioner training practice and higher self-reported adoption were significantly associated with higher review activity. (3) Effectiveness ranged from a relative increase in high-risk prescribing of 24.1% to a relative reduction of 77.2%. High-risk prescribing and DQIP adoption (but not documented review activity) were significantly associated with greater effectiveness in the final multivariate model, explaining 64.0% of variation in effectiveness. CONCLUSIONS Intervention implementation and effectiveness of the DQIP intervention varied substantially between practices. Although the DQIP intervention primarily targeted review of ongoing high-risk prescribing, the finding that self-reported DQIP adoption was a stronger predictor of effectiveness than documented review activity supports that reducing initiation and/or re-initiation of high-risk prescribing is key to its effectiveness. TRIAL REGISTRATION NUMBER NCT01425502; Post-results.
Collapse
Affiliation(s)
- Tobias Dreischulte
- Prescribing Support Unit, NHS Tayside, Dundee, UK
- Population Health Sciences Division, Medical Research Institute, University of Dundee, Dundee, UK
| | - Aileen Grant
- School of Nursing and Midwifery, Robert Gordon University, Aberdeen, UK, Scotland
| | - Adrian Hapca
- Population Health Sciences Division, Medical Research Institute, University of Dundee, Dundee, UK
| | - Bruce Guthrie
- Population Health Sciences Division, Medical Research Institute, University of Dundee, Dundee, UK
| |
Collapse
|
33
|
How Can Safer Care Be Achieved? Patient Safety Officers' Perceptions of Factors Influencing Patient Safety in Sweden. J Patient Saf 2017; 16:155-161. [PMID: 29112035 DOI: 10.1097/pts.0000000000000262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aimed to survey health care professionals in Sweden on the factors that they believe have been most important in reaching the current level of patient safety and achieving safer care in the future as well as the characteristics of the county councils that have been the most successful in achieving safe care. METHODS The study population consisted of 222 patient safety officers, that is, health care professionals with strategic positions in patient safety work in the county councils. A postal questionnaire was used for data collection. RESULTS The survey response rate was 70%. The factors that were considered most important for the current level of patient safety were efforts to reduce the use of antibiotics; Swedish patient safety law; and internal discussions with the county council management, heads of health care units, health care providers, and so on. The factors that were considered most important to achieve safer care in the future were improved communication between health care practitioners and patients, improved organizational culture, improved communication, and patient safety knowledge as a compulsory component of basic education for health care practitioners. CONCLUSIONS Several factors rated highly for achieving the current level of patient safety are part of the government-supported financial incentive plan. Patient safety is attributed to a broad range of factors, and many solutions might contribute to improved patient safety in the future. The most successful county councils are characterized by leadership support for patient safety, well-organized patient safety work, long-term commitment to patient safety, and an organizational culture that is conducive to patient safety.
Collapse
|
34
|
Smeulers M, Vermeulen H. Best of both worlds: combining evidence with local context to develop a nursing shift handover blueprint. Int J Qual Health Care 2017; 28:749-757. [PMID: 27621080 DOI: 10.1093/intqhc/mzw101] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 08/03/2016] [Indexed: 12/20/2022] Open
Abstract
Objective Standardization of the handover process is deemed necessary to ensure continuity and safety of care. However, local context is considered of equal importance to improve the handover process. Our objective was to determine what recommendations on standardized shift handover nurses make, if we combine evidence from the literature with the local context of the nurses. Design A RAND-modified Delphi consensus process that combines evidence from systematic reviews with expert opinion of local nurses and an evaluation of the consensus process with a survey. Setting One academic medical center in the Netherlands. Participants Twenty nurses from surgical, medical, neurological, psychiatric, cardiology, children's and gynecology departments. Results Four systematic reviews on nursing handover were included to compose provisional recommendations on how, what, where and the preconditions of shift handover. Nurses reached consensus on a final set of 18 recommendations for a nursing shift handover blueprint: how (1 recommendation), what (12 recommendations), where (3 recommendations) and the preconditions (2 recommendations), which were structured with the mnemonic NURSEPASS. The nurses assessed the method as an effective approach to develop a local blueprint. Conclusions Evidence-based consensus is a feasible method to combine evidence from the literature with local context. We anticipate that implementation of the resulting tailored blueprint for nursing shift handover will be facilitated due to the method used. Through evaluation of its effectiveness, we intend to add to the body of evidence on development and implementation of effective nursing handover, which is an essential link for continuity and safety of care.
Collapse
Affiliation(s)
- Marian Smeulers
- Department of Quality Assurance and Process Innovation, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Hester Vermeulen
- Department of Surgery, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.,Department of Nursing, A msterdam School of Health Professions, Tafelbergweg 51, 1105 BC Amsterdam, The Netherlands
| |
Collapse
|
35
|
Panagos PG, Pearlman SA. Creating a Highly Reliable Neonatal Intensive Care Unit Through Safer Systems of Care. Clin Perinatol 2017; 44:645-662. [PMID: 28802344 DOI: 10.1016/j.clp.2017.05.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Neonates requiring intensive care are at high risk for medical errors due to their unique characteristics and high acuity. Designing a safer work environment begins with safe processes. Creating a culture of safety demands the involvement of all organizational levels and an interdisciplinary approach. Adverse events can result from suboptimal communication and lack of a shared mental model. This chapter describes tools to promote better patient safety in the NICU through monitoring adverse events, improving communication and using information technology. Unplanned extubation is an example of a neonatal safety concern that can be reduced by employing quality improvement methodology.
Collapse
Affiliation(s)
- Patoula G Panagos
- Division of Neonatology, Nemours Alfred I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE 19803, USA; Nemours Neonatology, Thomas Jefferson University Hospital, Philadelphia, PA, USA; Sidney Kimmel School of Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Stephen A Pearlman
- Sidney Kimmel School of Medicine, Thomas Jefferson University, Philadelphia, PA, USA; Division of Neonatology, Women and Children's Services, Christiana Care Health System, MAP I Suite 217, Newark, DE 19713, USA.
| |
Collapse
|
36
|
Use of Cascading A3s to Drive Systemwide Improvement. Jt Comm J Qual Patient Saf 2017; 43:422-428. [DOI: 10.1016/j.jcjq.2017.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
37
|
Alaloul F, Williams K, Myers J, Jones KD, Sullivan K, Logsdon MC. Contextual Factors Impacting a Pain Management Intervention. J Nurs Scholarsh 2017; 49:504-512. [DOI: 10.1111/jnu.12319] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Fawwaz Alaloul
- Iota Zeta, Assistant Professor, School of Nursing; Health Sciences Campus; K-Wing Louisville KY USA
| | - Kimberly Williams
- Acute Pain Service Charge Nurse; University of Louisville Hospital; Louisville KY USA
| | - John Myers
- Associate Professor, Department of Pediatrics; School of Medicine, Health Sciences Campus; Louisville KY USA
| | | | - Katelyn Sullivan
- Student, School of Nursing; Health Sciences Campus; Louisville KY USA
| | - M. Cynthia Logsdon
- Alpha and Iota Gamma, Professor, School of Nursing, University of Louisville; Associate Chief of Nursing for Research, University of Louisville Hospital; James Graham Brown Cancer Center; Louisville KY USA
| |
Collapse
|
38
|
Guise JM, Hansen M, Lambert W, O’Brien K. The role of simulation in mixed-methods research: a framework & application to patient safety. BMC Health Serv Res 2017; 17:322. [PMID: 28472958 PMCID: PMC5418848 DOI: 10.1186/s12913-017-2255-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 04/20/2017] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Research in patient safety is an important area of health services research and is a national priority. It is challenging to investigate rare occurrences, explore potential causes, and account for the complex, dynamic context of healthcare - yet all are required in patient safety research. Simulation technologies have become widely accepted as education and clinical tools, but have yet to become a standard tool for research. METHODS We developed a framework for research that integrates accepted patient safety models with mixed-methods research approaches and describe the performance of the framework in a working example of a large National Institutes of Health (NIH)-funded R01 investigation. RESULTS This worked example of a framework in action, identifies the strengths and limitations of qualitative and quantitative research approaches commonly used in health services research. Each approach builds essential layers of knowledge. We describe how the use of simulation ties these layers of knowledge together and adds new and unique dimensions of knowledge. CONCLUSIONS A mixed-methods research approach that includes simulation provides a broad multi-dimensional approach to health services and patient safety research.
Collapse
Affiliation(s)
- Jeanne-Marie Guise
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239 USA
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239 USA
- Department of Emergency Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239 USA
- Department of Public Health and Preventive Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239 USA
| | - Matthew Hansen
- Department of Emergency Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239 USA
| | - William Lambert
- Department of Public Health and Preventive Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239 USA
| | - Kerth O’Brien
- Department of Psychology, Portland State University, PO Box 751, Portland, OR 97207 USA
| |
Collapse
|
39
|
López-Picazo JJ, Ferrer-Bas P, Garrido-Corro B, Pujalte-Ródenas V, de la Cruz Murie P, Blázquez-Pedrero M, Sánchez-Lorca S, Soler-Gallego P, Albacete-Moreno C, Alcaraz-Pérez T, Pérez-Romero S. [Effectiveness of an intervention to improve safety culture. Less is more?]. REVISTA DE CALIDAD ASISTENCIAL : ORGANO DE LA SOCIEDAD ESPANOLA DE CALIDAD ASISTENCIAL 2017; 32:146-154. [PMID: 28162926 DOI: 10.1016/j.cali.2016.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 09/05/2016] [Accepted: 09/20/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To assess the impact of a long-term initiative to improve safety culture among professionals working in a Health Area, and to know their perceived usefulness. MATERIAL AND METHODS An uncontrolled intervention study was designed in a public health care organization including a 3rd level hospital and 5,000 professionals. To measure the impact, the AHRQ Survey was conducted by telephone. A total of 7 dimensions of culture were measured, before starting the project (2012, n=100) and 3 years later (2015, n=207). Variations between 2012 and the respondents aware of the project in 2015 (RAP) were compared, as also between this last group and the rest of respondents (RNAP). The utility was assessed using a 5-item Likert scale, defining higher utility by medians 4 or higher. RESULTS The response rates were above 80%. In 2015, the 41.5% of respondents were RAP (95%CI: 34.8-48.3), which was perceived as of high utility. Negative variations were detected in "sense of security" (-9.9%, P<.01, vs. 2012, and -4.2% between 2015 groups) and "feedback and communication errors" (-10.0% vs. 2012, and -8.9% between 2015 groups, P<.05). There was a not-significant positive variation in "openness in communication" (1.3% vs. 2012, and 6.9% between 2015 groups). The "management support" showed a not-significant improve in 2015 (37.0%, 95%CI: 30.9-43.1, in RAP; and 38.3%, 95%CI: 33.1-43.4, in RANP) in comparison to 2012 (31.4%, 95%CI: 28.4-39.7). CONCLUSIONS A paradoxical worsening is detected in several dimensions, this probably due to immaturity of the organization and the instrument used. Thus, tools explicitly considering the degree of maturity may be more appropriate to measure cultural changes, although more studies are needed.
Collapse
Affiliation(s)
- J J López-Picazo
- Unidad de Calidad Asistencial, Núcleo de Seguridad del Área 1 Murcia-Oeste, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, España.
| | - P Ferrer-Bas
- Área de Calidad de Enfermería, Núcleo de Seguridad del Área 1 Murcia-Oeste, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, España
| | - B Garrido-Corro
- Servicio de Farmacia, Núcleo de Seguridad del Área 1 Murcia-Oeste, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, España
| | - V Pujalte-Ródenas
- Unidad de Atención al Usuario, Núcleo de Seguridad del Área 1 Murcia-Oeste, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, España
| | - P de la Cruz Murie
- Servicio de Farmacia, Núcleo de Seguridad del Área 1 Murcia-Oeste, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, España
| | - M Blázquez-Pedrero
- Grupo de Seguridad Quirúrgica, Núcleo de Seguridad del Área 1 Murcia-Oeste, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, España
| | - S Sánchez-Lorca
- Área de Calidad de Enfermería, Núcleo de Seguridad del Área 1 Murcia-Oeste, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, España
| | - P Soler-Gallego
- Diagnóstico por Imagen, Núcleo de Seguridad del Área 1 Murcia-Oeste, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, España
| | - C Albacete-Moreno
- Unidad de Cuidados Intensivos, Núcleo de Seguridad del Área 1 Murcia-Oeste, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, España
| | - T Alcaraz-Pérez
- Hospital Materno-Infantil, Núcleo de Seguridad del Área 1 Murcia-Oeste, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, España
| | - S Pérez-Romero
- Unidad de Calidad Asistencial, Núcleo de Seguridad del Área 1 Murcia-Oeste, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, España
| |
Collapse
|
40
|
Hauck KD, Wang S, Vincent C, Smith PC. Healthy Life-Years Lost and Excess Bed-Days Due to 6 Patient Safety Incidents: Empirical Evidence From English Hospitals. Med Care 2017; 55:125-130. [PMID: 27753744 PMCID: PMC5266418 DOI: 10.1097/mlr.0000000000000631] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND There is little satisfactory evidence on the harm of safety incidents to patients, in terms of lost potential health and life-years. OBJECTIVE To estimate the healthy life-years (HLYs) lost due to 6 incidents in English hospitals between the years 2005/2006 and 2009/2010, to compare burden across incidents, and estimate excess bed-days. RESEARCH DESIGN The study used cross-sectional analysis of the medical records of all inpatients treated in 273 English hospitals. Patients with 6 types of preventable incidents were identified. Total attributable loss of HLYs was estimated through propensity score matching by considering the hypothetical remaining length and quality of life had the incident not occurred. RESULTS The 6 incidents resulted in an annual loss of 68 HLYs and 934 excess bed-days per 100,000 population. Preventable pressure ulcers caused the loss of 26 HLYs and 555 excess bed-days annually. Deaths in low-mortality procedures resulted in 25 lost life-years and 42 bed-days. Deep-vein thrombosis/pulmonary embolisms cost 12 HLYs, and 240 bed-days. Postoperative sepsis, hip fractures, and central-line infections cost <6 HLYs and 100 bed-days each. DISCUSSION The burden caused by the 6 incidents is roughly comparable with the UK burden of Multiple Sclerosis (80 DALYs per 100,000), HIV/AIDS and Tuberculosis (63 DALYs), and Cervical Cancer (58 DALYs). There were marked differences in the harm caused by the incidents, despite the public attention all of them receive. Decision makers can use the results to prioritize resources into further research and effective interventions.
Collapse
Affiliation(s)
- Katharina D. Hauck
- Department of Infectious Disease Epidemiology, School of Public Health, Faculty of Medicine, Imperial College London, London
| | | | - Charles Vincent
- Department of Experimental Psychology, Medical Sciences Division, University of Oxford, Oxford
| | - Peter C. Smith
- Imperial College Business School, Imperial College London, London, UK
| |
Collapse
|
41
|
Damery S, Flanagan S, Rai K, Combes G. Improving safety in care homes: protocol for evaluation of the Walsall and Wolverhampton care home improvement programme. BMC Health Serv Res 2017; 17:86. [PMID: 28122616 PMCID: PMC5267410 DOI: 10.1186/s12913-017-2013-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 01/13/2017] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Improving safety in care homes is becoming increasingly important. Care home residents typically have multiple physical and/or cognitive impairments, and adverse events like falls often lead to hospital attendance or admission. Developing a safety culture is associated with beneficial impacts on safety outcomes, but the complex needs of care home residents, coupled with staffing pressures in the sector, pose challenges for positive safety practices to become embedded at the individual and organisational levels. Staff training and education can positively enforce safety culture and reduce the incidence of harms, but improvement initiatives are often short lived and thorough evaluation is uncommon. This protocol outlines an evaluation of a large-scale care home improvement programme in the West Midlands. METHODS The programme will run in 35 care homes across Walsall and Wolverhampton over 24 months, and we anticipate that 30 care homes will participate in the evaluation (n = 1500 staff). The programme will train staff and managers in service improvement techniques, with the aim of strengthening safety culture and reducing adverse safety event rates. The evaluation will use a pre-post design with mixed methods. Quantitative data will focus on: care home manager and staff surveys administered at several time points and analysis of adverse event rates. Data on hospital activity by residents at participating care homes will be compared to matched controls. Qualitative data on experience of training and the application of learning to practice will be collected via semi-structured interviews with staff (n = 48 to 64) and programme facilitators (n = 6), and staff focus groups (n = 36 to 48 staff). The primary outcome measure is the change in mean score on the safety climate domain of the Safety Attitudes Questionnaire between baseline and programme end. DISCUSSION This mixed methods evaluation of a large-scale care home improvement programme will allow a substantial amount of qualitative and quantitative data to be collected. This will enable an assessment of the extent to which care home staff training can effectively improve safety culture, lower the incidence of adverse safety events such as falls and pressure ulcers, and potentially reduce care home resident's use of acute services.
Collapse
Affiliation(s)
- Sarah Damery
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, West Midlands, B15 2TT, USA.
| | - Sarah Flanagan
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, West Midlands, B15 2TT, USA
| | - Kiran Rai
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, West Midlands, B15 2TT, USA
| | - Gill Combes
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, West Midlands, B15 2TT, USA
| |
Collapse
|
42
|
Musuuza JS, Roberts TJ, Carayon P, Safdar N. Assessing the sustainability of daily chlorhexidine bathing in the intensive care unit of a Veteran's Hospital by examining nurses' perspectives and experiences. BMC Infect Dis 2017; 17:75. [PMID: 28088171 PMCID: PMC5237510 DOI: 10.1186/s12879-017-2180-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 01/02/2017] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Daily bathing with chlorhexidine gluconate (CHG) of intensive care unit (ICU) patients has been shown to reduce healthcare-associated infections and colonization by multidrug resistant organisms. The objective of this project was to describe the process of daily CHG bathing and identify the barriers and facilitators that can influence its successful adoption and sustainability in an ICU of a Veterans Administration Hospital. METHODS We conducted 26 semi-structured interviews with a convenience sample of 4 nurse managers (NMs), 13 registered nurses (RNs) and 9 health care technicians (HCTs) working in the ICU. We used qualitative content analysis to code and analyze the data. Dedoose software was used to facilitate data management and coding. Trustworthiness and scientific integrity of the data were ensured by having two authors corroborate the coding process, conducting member checks and keeping an audit trail of all the decisions made. RESULTS Duration of the interviews was 15 to 39 min (average = 26 min). Five steps of bathing were identified: 1) decision to give a bath; 2) ability to give a bath; 3) decision about which soap to use; 4) delegation of a bath; and 5) getting assistance to do a bath. The bathing process resulted in one of the following three outcomes: 1) complete bath; 2) interrupted bath; and 3) bath not done. The outcome was influenced by a combination of barriers and facilitators at each step. Most barriers were related to perceived workload, patient factors, and scheduling. Facilitators were mainly organizational factors such as the policy of daily CHG bathing, the consistent supply of CHG soap, and support such as reminders to conduct CHG baths by nurse managers. CONCLUSIONS Patient bathing in ICUs is a complex process that can be hindered and interrupted by numerous factors. The decision to use CHG soap for bathing was only one of 5 steps of bathing and was largely influenced by scheduling/workload and patient factors such as clinical stability, hypersensitivity to CHG, patient refusal, presence of IV lines and general hygiene. Interventions that address the organizational, provider, and patient barriers to bathing could improve adherence to a daily CHG bathing protocol.
Collapse
Affiliation(s)
- Jackson S Musuuza
- William S. Middleton Memorial Veterans Affairs Hospital, Madison, WI, USA.,Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Tonya J Roberts
- William S. Middleton Memorial Veterans Affairs Hospital, Madison, WI, USA.,School of Nursing, University of Wisconsin-Madison, Madison, WI, USA
| | - Pascale Carayon
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI, USA.,Center for Quality and Productivity Improvement, University of Wisconsin-Madison, Madison, WI, USA
| | - Nasia Safdar
- William S. Middleton Memorial Veterans Affairs Hospital, Madison, WI, USA. .,Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI, USA. .,Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
| |
Collapse
|
43
|
Kellogg KM, Hettinger Z, Shah M, Wears RL, Sellers CR, Squires M, Fairbanks RJ. Our current approach to root cause analysis: is it contributing to our failure to improve patient safety? BMJ Qual Saf 2016; 26:381-387. [PMID: 27940638 DOI: 10.1136/bmjqs-2016-005991] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 09/29/2016] [Accepted: 10/21/2016] [Indexed: 11/04/2022]
Abstract
BACKGROUND Despite over a decade of efforts to reduce the adverse event rate in healthcare, the rate has remained relatively unchanged. Root cause analysis (RCA) is a process used by hospitals in an attempt to reduce adverse event rates; however, the outputs of this process have not been well studied in healthcare. This study aimed to examine the types of solutions proposed in RCAs over an 8-year period at a major academic medical institution. METHODS All state-reportable adverse events were gathered, and those for which an RCA was performed were analysed. A consensus rating process was used to determine a severity rating for each case. A qualitative approach was used to categorise the types of solutions proposed by the RCA team in each case and descriptive statistics were calculated. RESULTS 302 RCAs were reviewed. The most common event types involved a procedure complication, followed by cardiopulmonary arrest, neurological deficit and retained foreign body. In 106 RCAs, solutions were proposed. A large proportion (38.7%) of RCAs with solutions proposed involved a patient death. Of the 731 proposed solutions, the most common solution types were training (20%), process change (19.6%) and policy reinforcement (15.2%). We found that multiple event types were repeated in the study period, despite repeated RCAs. CONCLUSIONS This study found that the most commonly proposed solutions were weaker actions, which were less likely to decrease event recurrence. These findings support recent attempts to improve the RCA process and to develop guidance for the creation of effective and sustainable solutions to be used by RCA teams.
Collapse
Affiliation(s)
- Kathryn M Kellogg
- MedStar Health, MedStar Institute for Innovation, Washington District of Columbia, USA
| | - Zach Hettinger
- MedStar Health, MedStar Institute for Innovation, Washington District of Columbia, USA
| | - Manish Shah
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin, USA
| | - Robert L Wears
- Department of Emergency Medicine/CSRU, University of Florida/Imperial College London, Jacksonville, Florida, USA
| | - Craig R Sellers
- University of Rochester School of Nursing, Rochester, New York, USA
| | | | - Rollin J Fairbanks
- MedStar Health, MedStar Institute for Innovation, Washington District of Columbia, USA
| |
Collapse
|
44
|
A Systematic Review of the Unintended Consequences of Clinical Interventions to Reduce Adverse Outcomes. J Patient Saf 2016; 12:173-179. [DOI: 10.1097/pts.0000000000000093] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
45
|
Zegers M, Hesselink G, Geense W, Vincent C, Wollersheim H. Evidence-based interventions to reduce adverse events in hospitals: a systematic review of systematic reviews. BMJ Open 2016; 6:e012555. [PMID: 27687901 PMCID: PMC5051502 DOI: 10.1136/bmjopen-2016-012555] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To provide an overview of effective interventions aimed at reducing rates of adverse events in hospitals. DESIGN Systematic review of systematic reviews. DATA SOURCES PubMed, CINAHL, PsycINFO, the Cochrane Library and EMBASE were searched for systematic reviews published until October 2015. STUDY SELECTION English-language systematic reviews of interventions aimed at reducing adverse events in hospitals, including studies with an experimental design and reporting adverse event rates, were included. Two reviewers independently assessed each study's quality and extracted data on the study population, study design, intervention characteristics and adverse patient outcomes. RESULTS Sixty systematic reviews with moderate to high quality were included. Statistically significant pooled effect sizes were found for 14 types of interventions, including: (1) multicomponent interventions to prevent delirium; (2) rapid response teams to reduce cardiopulmonary arrest and mortality rates; (3) pharmacist interventions to reduce adverse drug events; (4) exercises and multicomponent interventions to prevent falls; and (5) care bundle interventions, checklists and reminders to reduce infections. Most (82%) of the significant effect sizes were based on 5 or fewer primary studies with an experimental study design. CONCLUSIONS The evidence for patient-safety interventions implemented in hospitals worldwide is weak. The findings address the need to invest in high-quality research standards in order to identify interventions that have a real impact on patient safety. Interventions to prevent delirium, cardiopulmonary arrest and mortality, adverse drug events, infections and falls are most effective and should therefore be prioritised by clinicians.
Collapse
Affiliation(s)
- Marieke Zegers
- Radboud university medical center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
| | - Gijs Hesselink
- Radboud university medical center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
| | - Wytske Geense
- Radboud university medical center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
| | - Charles Vincent
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - Hub Wollersheim
- Radboud university medical center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
| |
Collapse
|
46
|
Car LT, Papachristou N, Bull A, Majeed A, Gallagher J, El-Khatib M, Aylin P, Rudan I, Atun R, Car J, Vincent C. Clinician-identified problems and solutions for delayed diagnosis in primary care: a PRIORITIZE study. BMC FAMILY PRACTICE 2016; 17:131. [PMID: 27613564 PMCID: PMC5017013 DOI: 10.1186/s12875-016-0530-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 09/01/2016] [Indexed: 11/10/2022]
Abstract
BACKGROUND Delayed diagnosis in primary care is a common, harmful and costly patient safety incident. Its measurement and monitoring are underdeveloped and underutilised. We created and implemented a novel approach to identify problems leading to and solutions for delayed diagnosis in primary care. METHODS We developed a novel priority-setting method for patient safety problems and solutions called PRIORITIZE. We invited more than 500 NW London clinicians via an open-ended questionnaire to identify three main problems and solutions relating to delayed diagnosis in primary care. 113 clinicians submitted their suggestions which were thematically grouped and synthesized into a composite list of 33 distinct problems and 27 solutions. A random group of 75 clinicians from the initial cohort scored these and an overall ranking was derived. The agreement between the clinicians' scores was presented using the Average Expert Agreement. RESULTS The top ranked problems were poor communication between secondary and primary care and the inverse care law, i.e. a mismatch between patients' medical needs and healthcare supply. The highest ranked solutions included: a more rigorous system of communicating abnormal results of investigations to patients, direct hotlines to specialists for GPs to discuss patient problems and better training of primary care clinicians in relevant areas. A priority highlighted throughout the findings is a need to improve communication between clinicians as well as with patients. The highest ranked suggestions had the highest consensus between experts. CONCLUSIONS The novel method we have developed is highly feasible, informative and scalable, and merits wider exploration with a view of becoming part of a routine pro-active and preventative system for patient safety assessment. Clinicians proposed a range of concrete suggestions with an emphasis on improving communication among clinicians and with patients and better GP training. In their view, delayed diagnosis can be largely prevented with interventions requiring relatively minor investment. Rankings of identified problems and solutions can serve as an aid to policy makers and commissioners of care in prioritization of scarce healthcare resources.
Collapse
Affiliation(s)
- Lorainne Tudor Car
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Nikolaos Papachristou
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Adrian Bull
- Imperial College Health Partners, London, UK
| | - Azeem Majeed
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Joseph Gallagher
- gHealth Research Group, UCD Conway Institute, University College Dublin School of Medicine, Dublin, Ireland
| | - Mona El-Khatib
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Paul Aylin
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Igor Rudan
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh Medical School, Edinburgh, UK
| | - Rifat Atun
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, USA
- Department of Health Policy and Management, Harvard T H Chan School of Public Health, Boston, USA
| | - Josip Car
- Health Services and Outcomes Research Programme, LKCMedicine, Nanyang Technological University, Singapore, Singapore
| | - Charles Vincent
- Department of Experimental Psychology, Medical Sciences Division, University of Oxford, Oxford, UK
| |
Collapse
|
47
|
|
48
|
Soban LM, Kim L, Yuan AH, Miltner RS. Organisational strategies to implement hospital pressure ulcer prevention programmes: findings from a national survey. J Nurs Manag 2016; 25:457-467. [PMID: 27487972 DOI: 10.1111/jonm.12416] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2016] [Indexed: 11/26/2022]
Abstract
AIM To describe the presence and operationalisation of organisational strategies to support implementation of pressure ulcer prevention programmes across acute care hospitals in a large, integrated health-care system. BACKGROUND Comprehensive pressure ulcer programmes include nursing interventions such as use of a risk assessment tool and organisational strategies such as policies and performance monitoring to embed these interventions into routine care. The current literature provides little detail about strategies used to implement pressure ulcer prevention programmes. METHODS Data were collected by an e-mail survey to all chief nursing officers in Veterans Health Administration acute care hospitals. Descriptive and bivariate statistics were used to summarise survey responses and evaluate relationships between some variables. RESULTS Organisational strategies that support implementation of a pressure ulcer prevention programme (policy, committee, staff education, wound care specialists, and use of performance data) were reported at high levels. Considerable variations were noted in how these strategies were operationalised within individual hospitals. CONCLUSION Organisational strategies to support implementation of pressure ulcer preventive programmes are often not optimally operationalised to achieve consistent, sustainable performance. IMPLICATIONS FOR NURSING MANAGEMENT The results of the present study highlight the role and influence of nurse leaders on pressure ulcer prevention program implementation.
Collapse
Affiliation(s)
- Lynn M Soban
- Cedars-Sinai Medical Center, Nursing Research and Development, Los Angeles, CA, USA
| | - Linda Kim
- Agency for Healthcare Research and Quality (AHRQ), Los Angeles Area Health Service Research (LAAHSR) Training Program, Department of Health Policy & Management, University of California School of Public Health, Los Angeles, CA, USA
| | - Anita H Yuan
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Rebecca S Miltner
- Department of Family, Community and Health Systems, School of Nursing, University of Alabama at Birmingham, Birmingham, AL, USA
| |
Collapse
|
49
|
Comparison of Recommendations in Clinical Practice Guidelines for Acute Gastroenteritis in Children. J Pediatr Gastroenterol Nutr 2016; 63:226-35. [PMID: 26835905 PMCID: PMC6858859 DOI: 10.1097/mpg.0000000000001133] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Acute gastroenteritis (AGE) is a major cause of child mortality and morbidity. This study aimed at systematically reviewing clinical practice guidelines (CPGs) on AGE to compare recommendations and provide the basis for developing single universal guidelines. METHODS CPGs were identified by searching MEDLINE, Cochrane-Library, National Guideline Clearinghouse and Web sites of relevant societies/organizations producing and/or endorsing CPGs. RESULTS The definition of AGE varies among the 15 CPGs identified. The parameters most frequently recommended to assess dehydration are skin turgor and sunken eyes (11/15, 73.3%), general appearance (11/15, 66.6%), capillary refill time, and mucous membranes appearance (9/15, 60%). Oral rehydration solution is universally recognized as first-line treatment. The majority of CPGs recommend hypo-osmolar (Na 45-60 mmol/L, 11/15, 66.6 %) or low-osmolality (Na 75 mmol/L, 9/15, 60%) solutions. In children who fail oral rehydration, most CPGs suggest intravenous rehydration (66.6%). However, nasogastric tube insertion for fluid administration is preferred according by 5/15 CPGs (33.3%). Changes in diet and withdrawal of food are discouraged by all CPGs, and early refeeding is strongly recommended in 13 of 15 (86.7%). Zinc is recommended as an adjunct to ORS by 10 of 15 (66.6%) CPGs, most of them from low-income countries. Probiotics are considered by 9 of 15 (60%) CPGs, 5 from high-income countries. Antiemetics are not recommended in 9 of 15 (60%) CPGs. Routine use of antibiotics is discouraged. CONCLUSIONS Key recommendations for the management of AGE in children are similar in CPGs. Together with accurate review of evidence-base this may represent a starting point for developing universal recommendations for the management of children with AGE worldwide.
Collapse
|
50
|
Abstract
Avoidable patient harm is a major public health concern, and may already have surpassed heart disease as the leading cause of death in the United States. While the public health community has contributed much to one aspect of patient harm prevention, infection control, the tools and techniques of public health have far more to offer to the emerging field of patient safety science. Patient safety practice has become increasingly professionalized in recent years, but specialist degree programs in the field remain scarce. Healthcare organizations should consider graduate training in public health as an avenue for investing in the professional development of patient safety practitioners, and schools and programs of public health should support further research and teaching to support patient safety improvement.
Collapse
|