Learning from practice variation to improve the quality of care

Physician antimicrobial prescribing and patient outcomes on general medical wards: a multicentre retrospective cohort study

BACKGROUND

Variability in antimicrobial prescribing may indicate an opportunity for improvement in antimicrobial use. We sought to measure physician-level antimicrobial prescribing in adult general medical wards, assess the contribution of patient-level factors to antimicrobial prescribing and evaluate the association between antimicrobial prescribing and clinical outcomes.

METHODS

Using the General Medicine Inpatient Initiative (GEMINI) database, we conducted a retrospective cohort study of physician-level volume and spectrum of antimicrobial prescribing in adult general medical wards in 4 academic teaching hospitals in Toronto, Ontario, between April 2010 and December 2019. We stratified physicians into quartiles by hospital site based on volume of antimicrobial prescribing (days of therapy per 100 patient-days and antimicrobial-free days) and antibacterial spectrum (modified spectrum score). The modified spectrum score assigns a value to each antibacterial agent based on the breadth of coverage. We assessed patient-level differences among physician quartiles using age, sex, Laboratory-based Acute Physiology Score, discharge diagnosis and Charlson Comorbidity Index. We evaluated the association of clinical outcomes (in-hospital 30-day mortality, length of stay, intensive care unit [ICU] transfer and hospital readmission) with antimicrobial volume and spectrum using multilevel modelling.

RESULTS

The cohort consisted of 124 physicians responsible for 124 158 hospital admissions. The median physician-level volume of antimicrobial prescribing was 56.1 (interquartile range 51.7-67.5) days of therapy per 100 patient-days. We did not find any differences in baseline patient characteristics by physician prescribing quartile. The difference in mean prescribing between quartile 4 and quartile 1 was 15.8 days of therapy per 100 patient-days (95% confidence interval [CI] 9.6-22.0), representing 30% higher antimicrobial prescribing in the fourth quartile than the first quartile. Patient in-hospital deaths, length of stay, ICU transfer and hospital readmission did not differ by physician quartile. In-hospital mortality was higher among patients cared for by prescribers with higher modified spectrum scores (odds ratio 1.13, 95% CI 1.04-1.24).

INTERPRETATION

We found that physician-level variability in antimicrobial prescribing was not associated with differences in patient characteristics or outcomes in academic general medicine wards. These findings provide support for considering the lowest quartile of physician antimicrobial prescribing within each hospital as a target for antimicrobial stewardship.

Measuring the quality of skin cancer management in primary care: A scoping review

Skin cancer is a growing global problem and a significant health and economic burden. Despite the practical necessity for skin cancer to be managed in primary care settings, little is known about how quality of care is or should be measured in this setting. This scoping review aimed to capture the breadth and range of contemporary evidence related to the measurement of quality in skin cancer management in primary care settings. Six databases were searched for relevant texts reporting on quality measurement in primary care skin cancer management. Data from 46 texts published since 2011 were extracted, and quality measures were catalogued according to the three domains of the Donabedian model of healthcare quality (structure, process and outcome). Quality measures within each domain were inductively analysed into 13 key emergent groups. These represented what were deemed to be the most relevant components of skin cancer management as related to structure, process or outcomes measurement. Four groups related to the structural elements of care provision (e.g. diagnostic tools and equipment), five related to the process of care delivery (e.g. diagnostic processes) and four related to the outcomes of care (e.g. poor treatment outcomes). A broad range of quality measures have been documented, based predominantly on articles using retrospective cohort designs; systematic reviews and randomised controlled trials were limited.

Following Evidence-Based Recommendations for Perioperative Pain Management after Cesarean Section Is Associated with Better Pain-Related Outcomes: Analysis of Registry Data

Women who have had a Cesarean Section (CS) frequently report severe pain and pain-related interference. One reason for insufficient pain treatment might be inconsistent implementation of evidence-based guidelines. We assessed the association between implementing three elements of care recommended by guidelines for postoperative pain management and pain-related patient-reported outcomes (PROs) in women after CS. The analysis relied on an anonymized dataset of women undergoing CS, retrieved from PAIN OUT. PAIN OUT, an international perioperative pain registry, provides clinicians with treatment assessment methodology and tools for patients to assess multi-dimensional pain-related PROs on the first postoperative day. We examined whether the care included [i] regional anesthesia with a neuraxial opioid OR general anesthesia with wound infiltration or a Transvesus Abdominis Plane block; [ii] at least one non-opioid analgesic at the full daily dose; and [iii] pain assessment and recording. Credit for care was given only if all three elements were administered (= “full”); otherwise, it was “incomplete”. A “Pain Composite Score-total” (PCStotal), evaluating outcomes of pain intensity, pain-related interference with function, and side-effects, was the primary endpoint in the total cohort (women receiving GA and/or RA) or a sub-group of women with RA only. Data from 5182 women was analyzed. “Full” care was administered to 20% of women in the total cohort and to 21% in the RA sub-group. In both groups, the PCStotal was significantly lower compared to “incomplete” care (p < 0.001); this was a small-to-moderate effect size. Administering all three elements of care was associated with better pain-related outcomes after CS. These should be straightforward and inexpensive for integration into routine care after CS. However, even in this group, a high proportion of women reported poor outcomes, indicating that additional work needs to be carried out to close the evidence-practice gap so that women who have undergone CS can be comfortable when caring for themselves and their newborn.

Some performance considerations when using multi-armed bandit algorithms in the presence of missing data

When comparing the performance of multi-armed bandit algorithms, the potential impact of missing data is often overlooked. In practice, it also affects their implementation where the simplest approach to overcome this is to continue to sample according to the original bandit algorithm, ignoring missing outcomes. We investigate the impact on performance of this approach to deal with missing data for several bandit algorithms through an extensive simulation study assuming the rewards are missing at random. We focus on two-armed bandit algorithms with binary outcomes in the context of patient allocation for clinical trials with relatively small sample sizes. However, our results apply to other applications of bandit algorithms where missing data is expected to occur. We assess the resulting operating characteristics, including the expected reward. Different probabilities of missingness in both arms are considered. The key finding of our work is that when using the simplest strategy of ignoring missing data, the impact on the expected performance of multi-armed bandit strategies varies according to the way these strategies balance the exploration-exploitation trade-off. Algorithms that are geared towards exploration continue to assign samples to the arm with more missing responses (which being perceived as the arm with less observed information is deemed more appealing by the algorithm than it would otherwise be). In contrast, algorithms that are geared towards exploitation would rapidly assign a high value to samples from the arms with a current high mean irrespective of the level observations per arm. Furthermore, for algorithms focusing more on exploration, we illustrate that the problem of missing responses can be alleviated using a simple mean imputation approach.

A scoping review of medical practice variation research within the informatics literature

RATIONALE

We performed a scoping review of informatics core literature about medical practice variation (MPV) as an agile summary of the subject in our field.

MATERIALS AND METHODS

The Ovid integrated database was searched between 1946 and 2022 to identify MPV studies published in major informatics journals and conference proceedings. Two reviewers performed relevance screening, with assistance from another independent reviewer for adjudication. The included articles were then thematically analyzed and summarized through discussion among all three reviewers.

RESULTS

A total of 43 articles were included and went through the thematic analysis. About half (n = 21) of the included articles were published in conference proceedings. Five articles reported the effect of MPV on patient outcomes. The variation of interest was most frequently in treatment decisions. In terms of the role informatics played (multiple roles allowed), 39 (90.7%) articles pertained to detection of MPV, 5 were about prevention of MPV and 4 about learning from MPV.

DISCUSSION

MPV remains a critical issue in health care, yet most informatics research has been focused on simple tasks such as automating the detection of MPV and assessing compliance to decision-support systems, and less focused on addressing the causes of variation or supporting learning from variation.

CONCLUSION

Our scoping review found that informatics studies have focused on detecting of MPV, especially variability in treatments and deviation from practice guidelines. Technological advances should promote more informatics research focused on explaining and learning from MPV.

Quality and variation of care for chronic kidney disease in Swiss general practice: A retrospective database study

Background

Chronic kidney disease (CKD) is a common condition in general practice. Data about quality and physician-level variation of CKD care provided by general practitioners is scarce. In this study, we evaluated determinants and variation of achievement of 14 quality indicators for CKD care using electronic medical records data from Swiss general practice during 2013–2019.

Methods

We defined two patient cohorts from 483 general practitioners, one to address renal function assessment in patients with predisposing conditions (n = 47,201, median age 68 years, 48.7% female) and one to address care of patients with laboratory-confirmed CKD (n = 14,654, median age 80 years, 57.5% female). We investigated quality indicator achievement with mixed-effect logistic regression and expressed physician-level variation as intraclass correlation coefficients (ICCs) and range odds ratios (rORs).

Results

We observed the highest quality indicator achievement rate for withholding non-steroidal anti-inflammatory drug prescription in patients with CKD staged G2–3b within 12 months of follow-up (82.6%), the lowest for albuminuria assessment within 18 months of follow-up (18.1%). Highest physician-level variation was found for renal function assessment during 18 months of follow-up in patients with predisposing conditions (diabetes: ICC 0.31, rOR 26.5; cardiovascular disease: ICC 0.28, rOR 17.4; hypertension: ICC 0.24, rOR 17.2).

Conclusion

This study suggests potentially unwarranted variation in general practice concerning RF assessment in patients affected by conditions predisposing for CKD. We further identified potential gaps in quality of CKD monitoring as well as lower quality of CKD care for female patients and patients not affected by comorbidities.

Practice Variation in Skin Cancer Treatment and Follow-Up Care: A Dutch Claims Database Analysis

BACKGROUND

Quality indicators are used to benchmark and subsequently improve quality of healthcare. However, defining good quality indicators and applying them to high-volume care such as skin cancer is not always feasible.

OBJECTIVES

To determine whether claims data could be used to benchmark high-volume skin cancer care and to assess clinical practice variation.

METHODS

All skin cancer care-related claims in dermatology in 2016 were extracted from a nationwide claims database (Vektis) in the Netherlands.

RESULTS

For over 220,000 patients, a skin cancer diagnosis-related group was reimbursed in 124 healthcare centres. Conventional excision reflected 75% of treatments for skin cancer but showed large variation between practices. Large practice variation was also found for 5-fluorouracil and imiquimod creams. The practice variation of Mohs micrographic surgery and photodynamic therapy was low under the 75th percentile, but outliers at the 100th percentile were detected, which indicates that few centres performed these therapies far more often than average. On average, patients received 1.8 follow-up visits in 2016.

CONCLUSIONS

Claims data demonstrated large practice variation in treatments and follow-up visits of skin cancer and may be a valid and feasible data set to extract quality indicators. The next step is to investigate whether detected practice variation is unwarranted and if a reduction improves quality and efficiency of care.

Using quality improvement to implement consensus guidelines for postnatal steroid treatment of preterm infants with developing bronchopulmonary dysplasia

OBJECTIVE

Achieve over 90% adherence to consensus guidelines on use of postnatal steroids (PNS) in preterm infants for bronchopulmonary dysplasia (BPD) within 6 months.

METHODS

A multidisciplinary team formulated and implemented consensus guidelines using the Plan-Do-Study-Act method of quality improvement. Outcome measure was rate of compliance to guidelines, process measure was age of starting PNS treatment, and balancing measure was rate of repeat steroid courses.

RESULTS

Retrospective application of guidelines to preceding 10 months showed mean baseline compliance rate of 71% (n = 42). After implementation, compliance escalated to a mean rate of 96% within 6 months. Rate of PNS treatment ≤ 30 days of life increased from 50 to 80%, while rate of repeat PNS was unchanged.

CONCLUSIONS

Compliance with new guidelines for PNS treatment of BPD was quickly attained using simple quality improvement interventions. Further study is needed to evaluate effects of these guidelines on clinical outcomes.

Motivation factors affecting the job attitude of medical doctors and the organizational performance of public hospitals in Warsaw, Poland

Background

This paper examines the relationship between selected motivation factors that affect the attitude to work among medical doctors at public hospitals and the organizational performance of hospitals.

Methods

This study was based on World Health Organization questionnaires designed to estimate motivation factors according to Herzberg’s motivation theory and to measure the level of organizational performance of hospitals by using the McKinsey model. A survey was conducted among physicians (n = 249) with either surgical (operative) or nonsurgical (conservative) specialty in 22 departments/units of general public hospitals in Warsaw, Poland.

The relationship between the chosen job motivation factors and organizational effectiveness was determined using Spearman’s rank correlation. Furthermore, 95% confidence intervals were calculated. The independent samples t-test was used to confirm statistically significant differences between the independent groups. Normality of the data was tested by the Kolmogorov–Smirnov test.

Results

The survey revealed that motivation factors related to “quality and style of supervision” have the highest effect on the organizational performance of hospitals (Spearman’s rank correlation coefficient = 0.490; p < 0.001), whereas “performance feedback” has the lowest effect on organizational performance according to the surveyed healthcare professionals (54% of physicians).

Conclusion

The principles of Individual Performance Review should be incorporated into strategies designed to improve the organizational performance of hospitals (with NHS serving as a potential role model) in order to establish specific rules on how to share performance feedback with individual physicians. The present study contributes to literature on human resource management in the healthcare sector and highlights the importance of nonfinancial aspects in improving the organizational performance of hospitals.

Can feedback approaches reduce unwarranted clinical variation? A systematic rapid evidence synthesis

Background

Assessment of clinical variation has attracted increasing interest in health systems internationally due to growing awareness about better value and appropriate health care as a mechanism for enhancing efficient, effective and timely care. Feedback using administrative databases to provide benchmarking data has been utilised in several countries to explore clinical care variation and to enhance guideline adherent care. Whilst methods for detecting variation are well-established, methods for determining variation that is unwarranted and addressing this are strongly debated. This study aimed to synthesize published evidence of the use of feedback approaches to address unwarranted clinical variation (UCV).

Methods

A rapid review and narrative evidence synthesis was undertaken as a policy-focused review to understand how feedback approaches have been applied to address UCV specifically. Key words, synonyms and subject headings were used to search the major electronic databases Medline and PubMed between 2000 and 2018. Titles and abstracts of publications were screened by two reviewers and independently checked by a third reviewer. Full text articles were screened against the eligibility criteria. Key findings were extracted and integrated in a narrative synthesis.

Results

Feedback approaches that occurred over a duration of 1 month to 9 years to address clinical variation emerged from 27 publications with quantitative (20), theoretical/conceptual/descriptive work (4) and mixed or multi-method studies (3). Approaches ranged from presenting evidence to individuals, teams and organisations, to providing facilitated tailored feedback supported by a process of ongoing dialogue to enable change. Feedback approaches identified primarily focused on changing clinician decision-making and behaviour. Providing feedback to clinicians was identified, in a range of a settings, as associated with changes in variation such as reducing overuse of tests and treatments, reducing variations in optimal patient clinical outcomes and increasing guideline or protocol adherence.

Conclusions

The review findings suggest value in the use of feedback approaches to respond to clinical variation and understand when action is warranted. Evaluation of the effectiveness of particular feedback approaches is now required to determine if there is an optimal approach to create change where needed.

A survey of postoperative pain treatments and unmet needs

More than 300 million patients undergo surgery worldwide each year. Pain associated with these procedures is associated with short- and long-term negative sequelae for patients, healthcare providers, and healthcare systems. The following chapter is a review of the reality of postoperative pain management in everyday clinical routine based on survey- and registry-derived data with a focus on care in adults. Between 30% and up to 80% of patients report moderate to severe pain in the days after surgery. Structures, processes, and outcomes vary widely between hospitals and indicate gaps between evidence-based findings and practice. Pain assessment is not effectively implemented in many hospitals and should consider cultural differences. Few data exist on the situation of pain management in low- and middle-income countries, indicating lack of resources and available medication in many of these areas. Certain types of surgery as well as demographic and clinical factors are associated with increased risk of severe postoperative pain.

Methods for development of structure, process and outcome indicators for prioritized spinal cord injury rehabilitation Domains: SCI-High Project

Background: High-quality rehabilitation care following spinal cord injury or disease (SCI/D) is critical for optimizing neurorecovery and long-term health outcomes. This manuscript describes the methods used for developing, refining, and implementing a framework of structure, process, and outcome indicators that reflect high-quality rehabilitation among adults with SCI/D in Canada. Methods: This quality improvement initiative was comprised of the following processes: (1) prioritization of care Domains by key stakeholders (scientists, clinicians, therapists, patients and stakeholder organizations); (2) assembly of 11 Domain-specific Working Groups including 69 content experts; (3) conduct of literature searches, guideline and best practice reviews, and outcome synthesis by the Project Team; (4) refinement of Domain aim and construct definitions; (5) conduct of cause and effect analysis using Driver diagrams; (6) selection and development of structure, process and outcome indicators; (7) piloting and feasibility analysis of indicators and associated evaluation tools; and, (8) dissemination of the proposed indicators. Result: The Project Team established aims, constructs and related structure, process, and outcome indicators to facilitate uniform measurement and benchmarking across 11 Domains of rehabilitation, at admission and for 18 months thereafter, among adult Canadians by 2020. Conclusion: These processes led to the selection of a feasible set of indicators that once implemented should ensure that adults with SCI/D receive timely, safe, and effective rehabilitation services. These indicators can be used to assess health system performance, monitor the quality of care within and across rehabilitation settings, and evaluate the rehabilitation outcomes of the population to ultimately enhance healthcare quality and equity.

The use of process mapping in healthcare quality improvement projects

Introduction Process mapping provides insight into systems and processes in which improvement interventions are introduced and is seen as useful in healthcare quality improvement projects. There is little empirical evidence on the use of process mapping in healthcare practice. This study advances understanding of the benefits and success factors of process mapping within quality improvement projects. Methods Eight quality improvement projects were purposively selected from different healthcare settings within the UK's National Health Service. Data were gathered from multiple data-sources, including interviews exploring participants' experience of using process mapping in their projects and perceptions of benefits and challenges related to its use. These were analysed using inductive analysis. Results Eight key benefits related to process mapping use were reported by participants (gathering a shared understanding of the reality; identifying improvement opportunities; engaging stakeholders in the project; defining project's objectives; monitoring project progress; learning; increased empathy; simplicity of the method) and five factors related to successful process mapping exercises (simple and appropriate visual representation, information gathered from multiple stakeholders, facilitator's experience and soft skills, basic training, iterative use of process mapping throughout the project). Conclusions Findings highlight benefits and versatility of process mapping and provide practical suggestions to improve its use in practice.

Factors associated with retinopathy of prematurity ophthalmology workload

OBJECTIVE

This article reports on retinopathy of prematurity (ROP) workload in the NICU related to severity of disease, gestational age at discharge, and practice variation.

STUDY DESIGN

Data analysis on 1771 patients ≤ 30 weeks of gestation at birth from a de-identified data set of 13 NICUs.

RESULTS

There was a positive relationship between the severity of ROP and (1) the number of exams per patient, (2) the severity of ROP, and (3) postmenstrual age at discharge. The progression between the stages of ROP added to exam workload and postmenstrual age at NICU discharge. The addition of plus disease did not increase the exam burden. There was significant practice variation in the number of exams performed independent of ROP severity.

CONCLUSION

The progression of the severity of ROP independent of plus disease, and practice variations both contribute to ROP workload. Addressing these factors could decrease ROP workload without compromising American Academy of Pediatrics (AAP) guidelines.

Variation in quality of primary-care services in Kenya, Malawi, Namibia, Rwanda, Senegal, Uganda and the United Republic of Tanzania

Objective

To analyse factors affecting variations in the observed quality of antenatal and sick-child care in primary-care facilities in seven African countries.

Methods

We pooled nationally representative data from service provision assessment surveys of health facilities in Kenya, Malawi, Namibia, Rwanda, Senegal, Uganda and the United Republic of Tanzania (survey year range: 2006–2014). Based on World Health Organization protocols, we created indices of process quality for antenatal care (first visits) and for sick-child visits. We assessed national, facility, provider and patient factors that might explain variations in quality of care, using separate multilevel regression models of quality for each service.

Findings

Data were available for 2594 and 11  402 observations of clinical consultations for antenatal care and sick children, respectively. Overall, health-care providers performed a mean of 62.2% (interquartile range, IQR: 50.0 to 75.0) of eight recommended antenatal care actions and 54.5% (IQR: 33.3 to 66.7) of nine sick-child care actions at observed visits. Quality of antenatal care was higher in better-staffed and -equipped facilities and lower for physicians and clinical officers than nurses. Experienced providers and those in better-managed facilities provided higher quality sick-child care, with no differences between physicians and nurses or between better- and less-equipped clinics. Private facilities outperformed public facilities. Country differences were more influential in explaining variance in quality than all other factors combined.

Conclusion

The quality of two essential primary-care services for women and children was weak and varied across and within the countries. Analysis of reasons for variations in quality could identify strategies for improving care.

Implementation of Hysterectomy Pathway: Impact on Complications

OBJECTIVE

Hysterectomy is one of the most common surgical procedures in the United States. For women who need hysterectomy, it is important to ensure that minimally invasive hysterectomy procedures are used appropriately to reduce surgical complications and improve value of care. Although we previously demonstrated a reduction in total abdominal hysterectomy rates after the implementation of hysterectomy pathway treatment algorithm in 2012, this study focuses on exploring the effect of pathways implementation on surgical outcomes.

METHODS

All retrospective medical records for hysterectomy surgeries performed for benign indications at University of Pittsburgh Medical Center hospitals between the fiscal years (FY) 2012 and 2014 were identified. We analyzed the health care outcomes by route of surgery and year using Χ² test for categorical data, and non-parametric approaches for non-normal continuous variables.

RESULTS

A total of 6,569 hysterectomies for benign indications were performed between FY 2012 and 2014. In FY 2012, 1,154 patients (59.15%) had a length of stay of 1 day or less, whereas in FY 2014 this number increased to 1,791 (74.53%; p < .0001). Within 3 years of implementing the pathway, surgical site infections had a reduction of 47%, with a considerable trend toward significance (p = .067).

CONCLUSIONS

Implementation of hysterectomy pathway has been associated with reduction of surgical complications in benign hysterectomy settings. Implementation of clinical pathways offers an opportunity for improving patient outcomes that should be investigated in various health care settings and across procedures.

Missed Opportunity to Deprescribe: Docusate for Constipation in Medical Inpatients

BACKGROUND

Hospital admissions provide an opportunity to deprescribe ineffective medications and reduce pill burden. Docusate sodium is a stool softener that is frequently prescribed to treat constipation despite poor evidence for efficacy, thus providing a good target for deprescription. The aims of this study were to characterize rates of use and discontinuation of docusate among internal medicine inpatients, as well as use of other laxatives.

METHODS

We conducted a retrospective observational study over 1 year on all patients admitted to internal medicine at 2 urban academic hospitals to determine rates of docusate use. We also evaluated laxative and opioid medication use on a random sample of 500 inpatients who received docusate to characterize patterns of prescription and deprescription.

RESULTS

Fifteen percent (1169/7581) of all admitted patients received 1 or more doses of docusate. Among our random sample, 53% (238/452) received docusate before admission, and only 13% (31/238) had docusate deprescribed. Among patients not receiving docusate before admission, 33.2% (71/214) received a new prescription for docusate on discharge. Patients receiving opioids were frequently prescribed no laxatives or given docusate monotherapy (28%, 51/185).

CONCLUSIONS

Docusate was frequently prescribed to medical inpatients despite its known ineffectiveness, with low deprescription and high numbers of new prescriptions. Docusate use was common even among patients at high risk of constipation. One third of patients not receiving docusate before admission were prescribed docusate on discharge, potentially exacerbating polypharmacy. Among patients already receiving docusate, 80% had it continued on discharge, indicating significant missed opportunities for deprescribing. Given the availability of effective alternatives, our results suggest that quality-improvement initiatives are needed to promote evidence-based laxative use in hospitalized patients.

Using run charts for cardiovascular disease risk assessments in general practice

INTRODUCTION Run charts are quality improvement tools. AIM To investigate the feasibility and acceptability of run charts displaying weekly cardiovascular disease (CVD) risk assessments in general practice and assess their impact on CVD risk assessments. METHODS A controlled non-randomised observational study in nine practices using run charts and nine control practices. We measured the weekly proportion of eligible patients with completed CVD risk assessments for 19 weeks before and after run charts were introduced into intervention practices. A random coefficients model determined changes in CVD risk assessment rates (slope) from pre- to post- intervention by aggregating and comparing intervention and control practices' mean slopes. We interviewed staff in intervention practices about their use of run charts. RESULTS Seven intervention practices used their run chart; six consistently plotting weekly data for >12 weeks and positioning charts in a highly visible place. Staff reported that charts were easy to use, a visual reminder for ongoing team efforts, and useful for measuring progress. There were no significant differences between study groups: the mean difference in pre- to post-run chart slope in the intervention group was 0.03% more CVD risk assessments per week; for the control group the mean difference was 0.07%. The between group difference was 0.04% per week (95% CI: -0.26 to 0.35, P = 0.77). DISCUSSION Run charts are feasible in everyday general practice and support team processes. There were no differences in CVD risk assessment between the two groups, likely due to national targets driving performance at the time of the study.

Determining doctors' views on performance measurement and management of their clinical practice

Introducing performance measurement and management of clinicians' practice may improve clinical productivity and quality of patient care; however the attitudes of doctors to such approaches are poorly defined. This was investigated through an anonymous qualitative postal questionnaire in a large district general hospital. A total of 93 from an invited cohort of 368 senior grade doctors participated. The results suggested that doctors understood the need to evaluate and manage their performance in medical practice, and address poor performance, but felt that current methods were inadequate. This principally related to poor validation and a lack of clinical ownership of data. The role of financial incentivisation was unclear but value was attributed to local clinical leadership, professional autonomy, recognition, and peer-group comparisons. This suggests that clinicians support the use of data-based performance measurement and management; however how it is undertaken is key to successful clinical engagement.

Managing hospital doctors and their practice: what can we learn about human resource management from non-healthcare organisations?

Background

Improved management of clinicians’ time and practice is advocated to address increasing demands on healthcare provision in the UK National Health Service (NHS). Human resource management (HRM) is associated with improvements in organisational performance and outcomes within and outside of healthcare, but with limited use in managing individual clinicians. This may reflect the absence of effective and transferrable models.

Methods

The current systems of managing the performance of individual clinicians in a secondary healthcare organisation were reviewed through the study of practice in 10 successful partnership organisations, including knowledge worker predominant, within commercial, public and voluntary sector operating environments. Reciprocal visits to the secondary healthcare environment were undertaken.

Results

Six themes in performance related HRM were identified across the external organisations representing best practice and considered transferrable to managing clinicians in secondary care organisations. These included: performance measurement through defined outcomes at the team level with decision making through local data interpretation; performance improvement through empowered formal leadership with organisational support; individual performance review (IPR); and reward, recognition and talent management. The role of the executive was considered essential to support and implement effective HRM, with management of staff performance, behaviour and development integrated into organisational strategy, including through the use of universally applied values and effective communication. These approaches reflected many of the key aspects of high performance work systems and strategic HRM.

Conclusions

There is the potential to develop systems of HRM of individual clinicians in secondary healthcare to improve practice. This should include both performance measurement and performance improvement but also engagement at an organisational level. This suggests that effective HRM and performance management of individual clinicians may be possible but requires an alternative approach for the NHS.

An analysis of patient safety incidents associated with medications reported from critical care units in the North West of England between 2009 and 2012

Incident reporting is promoted as a key tool for improving patient safety in healthcare. We analysed 2238 patient safety incidents involving medications submitted from up to 29 critical care units each year in the North West of England between 2009 and 2012; 452 (20%) of these incidents led to harm to patients. Although 1461 (65%) incidents were judged to have been preventable, there was no reduction in the rate of incidents per 1000 days between 2009 and 2012 (5.9 in 2009, 6.6 in 2012). Furthermore, in the 2012 data, there were wide variations in the incident rates between units, the median (IQR [range]) rate per 1000 patient days for individual units being 6.8 (3.8-11.0 [1.3-37.1]). The variation in the percentage that could have been avoided was narrower, with a median (IQR [range]) of 70% (61-80% [38-100%]). The most commonly reported drugs were noradrenaline (161 incidents, 92 with harm), heparins (153 incidents, 29 with harm), morphine (131 incidents, 14 with harm) and insulin (111 incidents, 54 with harm). The administration of drugs was the stage in the process where incidents were most commonly reported; it was also the stage most likely to harm patients. We conclude that the wide range in reported rates between units, and the scope for preventing many incidents, suggest that quality improvement initiatives could improve medication safety in the units studied.