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Paxino J, Szabo RA, Marshall S, Story D, Molloy E. What and when to debrief: a scoping review examining interprofessional clinical debriefing. BMJ Qual Saf 2024; 33:314-327. [PMID: 38160060 DOI: 10.1136/bmjqs-2023-016730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 12/08/2023] [Indexed: 01/03/2024]
Abstract
INTRODUCTION Clinical debriefing (CD) improves teamwork and patient care. It is implemented across a range of clinical contexts, but delivery and structure are variable. Furthermore, terminology to describe CD is also inconsistent and often ambiguous. This variability and the lack of clear terminology obstructs understanding and normalisation in practice. This review seeks to examine the contextual factors relating to different CD approaches with the aim to differentiate them to align with the needs of different clinical contexts. METHODS Articles describing CD were extracted from Medline, CINAHL, ERIC, PubMed, PsychINFO and Academic Search Complete. Empirical studies describing CD that involved two or more professions were eligible for inclusion. Included papers were charted and analysed using the Who-What-When-Where-Why-How model to examine contextual factors which were then used to develop categories of CD. Factors relating to what prompted debriefing and when debriefing occurred were used to differentiate CD approaches. RESULTS Forty-six papers were identified. CD was identified as either prompted or routine, and within these overarching categories debriefing was further differentiated by the timing of the debrief. Prompted CD was either immediate or delayed and routine CD was postoperative or end of shift. Some contextual factors were unique to each category while others were relatively heterogeneous. These categories help clarify the alignment between the context and the intention of CD. CONCLUSIONS The proposed categories offer a practical way to examine and discuss CD which may inform decisions about implementation. By differentiating CD according to relevant contextual factors, these categories may reduce confusion which currently hinders discourse and implementation. The findings from this review promote context-specific language and a shift away from conceptions of CD that embody a one-size-fits-all approach.
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Affiliation(s)
- Julia Paxino
- Department of Medical Education, The University of Melbourne, Melbourne, Victoria, Australia
| | - Rebecca A Szabo
- Department of Medical Education, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Stuart Marshall
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - David Story
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Elizabeth Molloy
- Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
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Arrington LA, Kramer B, Ogunwole SM, Harris TL, Dankwa L, Knight S, Creanga AA, Bower KM. Interrupting false narratives: applying a racial equity lens to healthcare quality data. BMJ Qual Saf 2024; 33:340-344. [PMID: 38216312 DOI: 10.1136/bmjqs-2023-016612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 12/08/2023] [Indexed: 01/14/2024]
Affiliation(s)
| | - Briana Kramer
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | | | - Lois Dankwa
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Andreea A Creanga
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kelly M Bower
- Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
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Dunn M, Strnadová I, Scully JL, Hansen J, Loblinzk J, Sarfaraz S, Molnar C, Palmer EE. Equitable and accessible informed healthcare consent process for people with intellectual disability: a systematic literature review. BMJ Qual Saf 2024; 33:328-339. [PMID: 38071590 DOI: 10.1136/bmjqs-2023-016113] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 10/25/2023] [Indexed: 04/26/2024]
Abstract
OBJECTIVE To identify factors acting as barriers or enablers to the process of healthcare consent for people with intellectual disability and to understand how to make this process equitable and accessible. DATA SOURCES Databases: Embase, MEDLINE, PsychINFO, PubMed, SCOPUS, Web of Science and CINAHL. Additional articles were obtained from an ancestral search and hand-searching three journals. ELIGIBILITY CRITERIA Peer-reviewed original research about the consent process for healthcare interventions, published after 1990, involving adult participants with intellectual disability. SYNTHESIS OF RESULTS Inductive thematic analysis was used to identify factors affecting informed consent. The findings were reviewed by co-researchers with intellectual disability to ensure they reflected lived experiences, and an easy read summary was created. RESULTS Twenty-three studies were included (1999 to 2020), with a mix of qualitative (n=14), quantitative (n=6) and mixed-methods (n=3) studies. Participant numbers ranged from 9 to 604 people (median 21) and included people with intellectual disability, health professionals, carers and support people, and others working with people with intellectual disability. Six themes were identified: (1) health professionals' attitudes and lack of education, (2) inadequate accessible health information, (3) involvement of support people, (4) systemic constraints, (5) person-centred informed consent and (6) effective communication between health professionals and patients. Themes were barriers (themes 1, 2 and 4), enablers (themes 5 and 6) or both (theme 3). CONCLUSIONS Multiple reasons contribute to poor consent practices for people with intellectual disability in current health systems. Recommendations include addressing health professionals' attitudes and lack of education in informed consent with clinician training, the co-production of accessible information resources and further inclusive research into informed consent for people with intellectual disability. PROSPERO REGISTRATION CRD42021290548.
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Affiliation(s)
- Manjekah Dunn
- Faculty of Medicine & Health, University of New South Wales, Sydney, New South Wales, Australia
- The Sydney Children's Hospitals Network, Sydney, New South Wales, Australia
| | - Iva Strnadová
- School of Education, University of New South Wales, Sydney, New South Wales, Australia
- Disability Innovation Institute, University of New South Wales, Sydney, New South Wales, Australia
- Self Advocacy Sydney, Sydney, New South Wales, Australia
| | - Jackie Leach Scully
- Disability Innovation Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Jennifer Hansen
- School of Education, University of New South Wales, Sydney, New South Wales, Australia
| | - Julie Loblinzk
- School of Education, University of New South Wales, Sydney, New South Wales, Australia
- Self Advocacy Sydney, Sydney, New South Wales, Australia
| | - Skie Sarfaraz
- Self Advocacy Sydney, Sydney, New South Wales, Australia
| | - Chloe Molnar
- Faculty of Medicine & Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Elizabeth Emma Palmer
- Faculty of Medicine & Health, University of New South Wales, Sydney, New South Wales, Australia
- The Sydney Children's Hospitals Network, Sydney, New South Wales, Australia
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Hassan W, Naveed A, Khan Z. Project to improve the management of the head injury patients presenting to the emergency department. BMJ Open Qual 2024; 13:e002603. [PMID: 38663928 PMCID: PMC11043753 DOI: 10.1136/bmjoq-2023-002603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 03/28/2024] [Indexed: 04/28/2024] Open
Abstract
INTRODUCTION At Sandwell General Hospital, there was no risk stratification tool or pathway for head injury (HI) patients presenting to the emergency department (ED). This resulted in significant delays in the assessment of HI patients, compromising patient safety and quality of care. AIMS To employ quality improvement methodology to design an effective adult HI pathway that: ensured >90% of high-risk HI patients being assessed by ED clinicians within 15 min of arrival, reduce CT turnaround times, and aiming to keep the final decision making <4 hours. METHODS SWOT analysis was performed; driver diagrams were used to set out the aims and objectives. Plan-Do-Study-Act cycle was used to facilitate the change and monitor the outcomes. Process map was designed to identify the areas for improvement. A new HI pathway was introduced, imaging and transporting the patients was modified, and early decisions were made to meet the standards. RESULTS Data were collected and monitored following the interventions. The new pathway improved the proportion of patients assessed by the ED doctors within 15 min from 31% to 63%. The average time to CT head scan was decreased from 69 min to 53 min. Average CT scan reporting time also improved from 98 min to 71 min. Overall, the average time to decision for admission or discharge decreased from 6 hours 48 min to 4 hours 24 min. CONCLUSIONS Following implementation of the new HI pathway, an improvement in the patient safety and quality of care was noted. High-risk HI patients were picked up earlier, assessed quicker and had CT head scans performed sooner. Decision time for admission/discharge was improved. The HI pathway continues to be used and will be reviewed and re-audited between 3 and 6 months to ensure the sustained improvement.
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Affiliation(s)
- Waseem Hassan
- Emergency Medicine, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Asif Naveed
- Emergency Medicine, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Zuhair Khan
- Worcestershire Royal Hospital, Worcester, UK
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Yu N, Punatar N, Shaikh U, Agrawal G. Can hospitalists improve COVID-19 vaccination rates? BMJ Open Qual 2024; 13:e002646. [PMID: 38649197 PMCID: PMC11043723 DOI: 10.1136/bmjoq-2023-002646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 03/13/2024] [Indexed: 04/25/2024] Open
Abstract
Three years after the start of the SARS-CoV-2 virus (COVID-19) pandemic, its effects continue to affect society and COVID-19 vaccination campaigns continue to be a topic of controversy and inconsistent practice. After experiencing spikes in COVID-19 cases, our University of California Davis Health Division of Hospital Medicine sought to understand the reasons underlying the low COVID-19 vaccination rates in our county and find approaches to improve the number of vaccinations among adults admitted to the inpatient setting. This quality improvement project aimed to increase COVID-19 primary and booster vaccine efforts through a multi-pronged approach of increased collaboration with specialised staff and optimisation of use of our electronic health record system.Our key interventions focused on developing a visual reminder of COVID-19 vaccine status using the functionality of our electronic medical record (EMR), standardising documentation of COVID-19 vaccine status and enhancing team-based vaccination discussions through team huddles and partnering with inpatient care coordinators. While our grassroots approach enhanced COVID-19 vaccination rates in the inpatient setting and had additional benefits such as increased collaboration among teams, system-level efforts often made a greater impact at our healthcare centre. For other institutions interested in increasing COVID-19 vaccination rates, our top three recommendations include integrating vaccination into pre-existing workflows, optimising EMR functionality and increasing vaccine accessibility in the inpatient setting.
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Affiliation(s)
- Nina Yu
- University of California Davis Health, Sacramento, CA, USA
| | - Nisha Punatar
- University of California Davis Health, Sacramento, CA, USA
| | - Ulfat Shaikh
- University of California Davis Health, Sacramento, CA, USA
| | - Garima Agrawal
- University of California Davis Health System, Sacramento, California, USA
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Wegwarth O, Hoffmann TC, Goldacre B, Spies C, Giese HA. General practitioners' risk literacy and real-world prescribing of potentially hazardous drugs: a cross-sectional study. BMJ Qual Saf 2024:bmjqs-2023-016979. [PMID: 38631907 DOI: 10.1136/bmjqs-2023-016979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 04/08/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND Overuse of medical care is a pervasive problem. Studies using hypothetical scenarios suggest that physicians' risk literacy influences medical decisions; real-world correlations, however, are lacking. We sought to determine the association between physicians' risk literacy and their real-world prescriptions of potentially hazardous drugs, accounting for conflicts of interest and perceptions of benefit-harm ratios in low-value prescribing scenarios. SETTING AND SAMPLE Cross-sectional study-conducted online between June and October 2023 via field panels of Sermo (Hamburg, Germany)-with a convenience sample of 304 English general practitioners (GPs). METHODS GPs' survey responses on their treatment-related risk literacy, conflicts of interest and perceptions of the benefit-harm ratio in low-value prescribing scenarios were matched to their UK National Health Service records of prescribing volumes for antibiotics, opioids, gabapentin and benzodiazepines and analysed for differences. RESULTS 204 GPs (67.1%) worked in practices with ≥6 practising GPs and 226 (76.0%) reported 10-39 years of experience. Compared with GPs demonstrating low risk literacy, GPs with high literacy prescribed fewer opioids (mean (M): 60.60 vs 43.88 prescribed volumes/1000 patients/6 months, p=0.016), less gabapentin (M: 23.84 vs 18.34 prescribed volumes/1000 patients/6 months, p=0.023), and fewer benzodiazepines (M: 17.23 vs 13.58 prescribed volumes/1000 patients/6 months, p=0.037), but comparable volumes of antibiotics (M: 48.84 vs 40.61 prescribed volumes/1000 patients/6 months, p=0.076). High-risk literacy was associated with lower conflicts of interest (ϕ = 0.12, p=0.031) and higher perception of harms outweighing benefits in low-value prescribing scenarios (p=0.007). Conflicts of interest and benefit-harm perceptions were not independently associated with prescribing behaviour (all ps >0.05). CONCLUSIONS AND RELEVANCE The observed association between GPs with higher risk literacy and the prescription of fewer hazardous drugs suggests the importance of risk literacy in enhancing patient safety and quality of care.
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Affiliation(s)
- Odette Wegwarth
- Heisenberg Chair for Medical Risk Literacy & Evidence-Based Decisions, Charité Universitätsmedizin Berlin Campus Charite Mitte, Berlin, Germany
- Adpative Rationality, Max-Planck-Institute for Human Development, Berlin, Germany
| | - Tammy C Hoffmann
- Faculty of Health Sciences and Medicine, Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Queensland, Australia
| | - Ben Goldacre
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Claudia Spies
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Helge A Giese
- Heisenberg Chair for Medical Risk Literacy & Evidence-Based Decisions, Charité Universitätsmedizin Berlin Campus Charite Mitte, Berlin, Germany
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Jain M, Meshram P, Bang A, Chauhan V, Datta V, Dhanireddy R. Implementation of a quality improvement initiative for standardising essential newborn care in a teaching public hospital in rural central India. BMJ Open Qual 2024; 13:e001869. [PMID: 38626941 PMCID: PMC11029480 DOI: 10.1136/bmjoq-2022-001869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 03/15/2024] [Indexed: 04/19/2024] Open
Abstract
OBJECTIVE Our aim was to refine the essential newborn care practices by employing the multidisciplinary peer team-led quality improvement (QI) projects. DESIGN In 2017, concerning the same, the department focused on early initiation of breast feeding, prevention of hypothermia within an hour of life and rational usage of antibiotics among babies admitted to neonatal intensive care unit (NICU). Baseline data reported the rate of initiation of breast feeding, hypothermia and antibiotic exposure rate as 35%, 78% and 75%, respectively. Root causes were analysed and a series of Plan-Do-Study-Act cycles were conducted to test the changes. The process of change was studied through run charts (whereas control charts were used for study purpose). RESULT After the implementation of the QI projects, the rate of initiation of breast feeding was found to be improved from 35% to 90%, the incidence of hypothermia got reduced from 78% to 10% and the antibiotic exposure rate declined from 75% to 20%. Along with the improvement in indicators related to essential newborn care, down the stream we found a decrease in the percentage of culture-positive sepsis rate in the NICU. CONCLUSION Peer team-led QI initiatives in a resource-limited setting proved beneficial in improving essential newborn care practices.
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Affiliation(s)
- Manish Jain
- Pediatrics, MGIMS, Wardha, Maharashtra, India
| | - Payal Meshram
- Paediatric, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Maharashtra, India
| | - Akash Bang
- Pediatrics, All India Institute of Medical Sciences, Nagpur, Maharashtra, India
| | - Varsha Chauhan
- Paediatric, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Maharashtra, India
| | - Vikram Datta
- Neonatology, Kalawati Saran Children's Hospital, New Delhi, India
- Neonatology, Lady Hardinge Medical College, New Delhi, India
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Priyanath Gupta A, Patel D, Lee JY, Volpentesta M, Schachter M, Persell SD. Health information technology tools to accelerate gastrointestinal evaluation in patients with iron deficiency anaemia: a cluster randomised controlled trial. BMJ Open Qual 2024; 13:e002565. [PMID: 38626940 PMCID: PMC11029187 DOI: 10.1136/bmjoq-2023-002565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 02/28/2024] [Indexed: 04/19/2024] Open
Abstract
OBJECTIVE System-level safety measures do not exist to ensure that patients with iron deficiency anaemia (IDA) undergo proper diagnostic evaluations. We sought to determine if a set of EHR (electronic health record) tools and an expedited referral workflow increase short-term completion of bidirectional endoscopy in higher risk patients with IDA. MATERIALS AND METHODS We conducted a pragmatic, cluster-randomised trial randomised by primary care physician (PCP) that included 16 PCPs and 316 patients with IDA. Physicians were randomised to intervention or control groups. Intervention components included a patient registry visible within the EHR, point-of-care alert and expedited diagnostic evaluation workflow for IDA. Outcomes were assessed at 120 days. The primary outcome was completion of bidirectional endoscopy. Secondary outcomes were any endoscopy completed or scheduled, gastroenterology consultation completed, and gastroenterology referral or endoscopy ordered or completed. RESULTS There were no differences in the primary or secondary outcomes. At 120 days, the primary outcome had occurred for 7 (4%) of the intervention group and 5 (3.5%) of the control group. For the three secondary outcomes, rates were 15 (8.6%), 12 (6.9%) and 39 (22.4%) for the immediate intervention group and 10 (7.0%), 9 (6.3%) and 25 (17.6%) for the control group, respectively, p>0.2. Lack of physician time to use the registry tools was identified as a barrier. DISCUSSION AND CONCLUSION Providing PCPs with lists of patients with IDA and a pathway for expedited evaluation did not increase rates of completing endoscopic evaluation in the short term. TRIAL REGISTRATION NUMBER NCT05365308.
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Affiliation(s)
- Aparna Priyanath Gupta
- Division of General Internal Medicine, Department of Medicine, Feinberg School of Medicine,Northwestern University, Chicago, Illinois, USA
| | - Dharmesh Patel
- Northwestern Medical Group Quality and Safety, Northwestern Memorial HealthCare Corp, Chicago, Illinois, USA
| | - Ji Young Lee
- Division of General Internal Medicine, Department of Medicine, Feinberg School of Medicine,Northwestern University, Chicago, Illinois, USA
| | - Michelle Volpentesta
- Department of Information Systems, Northwestern Memorial HealthCare Corp, Chicago, Illinois, USA
| | - Michael Schachter
- Department of Information Systems, Northwestern Memorial HealthCare Corp, Chicago, Illinois, USA
| | - Stephen D Persell
- Division of General Internal Medicine, Department of Medicine, Feinberg School of Medicine,Northwestern University, Chicago, Illinois, USA
- Center for Primary Care Innovation, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Kamran R, Jackman L, Laws A, Stepney M, Harrison C, Jain A, Rodrigues J. Patient and healthcare professional perspectives on the Practical Guide to Implementing PROMs in Gender-Affirming Care (PG-PROM-GAC): analysis of open-ended responses from patients and healthcare professionals. BMJ Open Qual 2024; 13:e002721. [PMID: 38569665 PMCID: PMC11002366 DOI: 10.1136/bmjoq-2023-002721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 03/12/2024] [Indexed: 04/05/2024] Open
Abstract
IMPORTANCE Several international calls have been made for evidence-based patient-reported outcome measure (PROM) implementation for gender-affirming care. The Practical Guide to Implementing PROMs in Gender-Affirming Care (PG-PROM-GAC) is a resource which can help guide PROM implementation efforts, developed using a three-phase participatory research approach with transgender and gender-diverse (TGD) patients and gender-affirming healthcare professionals. However, thoughts and perspectives from TGD patients and gender-affirming healthcare professionals on the PG-PROM-GAC need to be investigated. OBJECTIVE Investigate patient and healthcare professional perspectives on the PG-PROM-GAC through analysis of open-ended survey results. DESIGN Qualitative study analysing open-ended responses from TGD patients and gender-affirming healthcare professionals. SETTING Participants were recruited from a UK National Health System (NHS) gender clinic. PARTICIPANTS Patients receiving care at an NHS gender clinic and healthcare professionals working at an NHS gender clinic were eligible for participation. Eligible participants were invited to participate in this study via email. INTERVENTION Participants were sent an open-ended survey to collect responses on the PG-PROM-GAC. MAIN OUTCOMES AND MEASURES Data were thematically analysed by two independent researchers and interpreted following guidance from established methods in implementation science. RESULTS A total of 64 TGD patients and 9 gender-affirming healthcare professionals responded to the open-ended survey (mean (SD) age: 35 (16) and 48 (8), respectively). Four main themes emerged from the data: overall opinions and support for the PG-PROM-GAC, presentation of the PG-PROM-GAC, impact of gender clinic resources on PROM implementation and impact of PROM selection on implementation. Data were used to iterate the PG-PROM-GAC in response to participant feedback. CONCLUSIONS AND RELEVANCE The PG-PROM-GAC is an acceptable and feasible resource that can be used by clinicians, researchers and policymakers to guide PROM implementation for gender-affirming care settings, helping to align gender-affirming care with patient needs.
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Affiliation(s)
- Rakhshan Kamran
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Liam Jackman
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Anna Laws
- Northern Region Gender Dysphoria Service, Cumbria Northumberland Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | - Conrad Harrison
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Abhilash Jain
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Jeremy Rodrigues
- Department of Plastic Surgery, Buckinghamshire Healthcare NHS Trust, Amersham, UK
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
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Löfqvist N. Enhancing capability for continuous organisational improvement and learning in healthcare organisations: a systematic review of the literature 2013-2022. BMJ Open Qual 2024; 13:e002566. [PMID: 38569667 PMCID: PMC10989174 DOI: 10.1136/bmjoq-2023-002566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 03/24/2024] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND Healthcare organisations strive to meet their current and future challenges and need to increase their capacity for continuous organisational improvement and learning (COIL). A key aspect of this capacity is the development of COIL capability among employees. OBJECTIVE This systematic review aims to explore common attributes of interventions that contribute to the development of COIL capability in healthcare organisations and to explore possible facilitating and hindering factors. METHODS A comprehensive search was conducted in Scopus, MEDLINE and Business Source Complete for primary research studies in English or Swedish, in peer-reviewed journals, focusing on organisational improvements and learning in healthcare organisations. Studies were included if they were published between 2013 and 23 November 2022, reported outcomes on COIL capability, included organisations or groups, and were conducted in high-income countries. The included articles were analysed to identify themes related to successful interventions and factors influencing COIL capability. RESULTS Thirty-six articles were included, with two studies reporting unsuccessful attempts at increasing COIL capability. The studies were conducted in nine different countries, encompassing diverse units, with the timeframes varying from 15 weeks to 8 years, and they employed quantitative (n=10), qualitative (n=11) and mixed methods (n=15). Analysis of the included articles identified four themes for both attributes of interventions and the factors that facilitated or hindered successful interventions: (1) engaged managers with a strategic approach, (2) external training and guidance to develop internal knowledge, skills and confidence, (3) process and structure to achieve improvements and learning and (4) individuals and teams with autonomy, accountability, and safety. CONCLUSION This review provides insights into the intervention attributes that are associated with increasing COIL capability in healthcare organisations as well as factors that can have hindering or facilitating effects. Strategic management, external support, structured processes and empowered teams emerged as key elements for enhancing COIL capability.
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Affiliation(s)
- Ninni Löfqvist
- Department of Communication, Quality Management, and Information Systems, Mid Sweden University, Östersund, Sweden
- Department of Pediatrics, Region Västernorrland, Härnösand, Sweden
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Fatima S, Arshad A, Zafar A, Farrukh S, Rahim A, Nazar S, Zafar H. Journey of medication reconciliation compliance in a lower middle-income country: a retrospective chart review. BMJ Open Qual 2024; 13:e002527. [PMID: 38569666 PMCID: PMC10989168 DOI: 10.1136/bmjoq-2023-002527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 03/23/2024] [Indexed: 04/05/2024] Open
Abstract
OBJECTIVE There were three main objectives of the study: to determine the overall compliance of medication reconciliation over 4 years in a tertiary care hospital, to compare the medication reconciliation compliance between paper entry (initial assessment forms) and computerised physician order entry (CPOE), and to identify the discrepancies between the medication history taken by the physician at the time of admission and those collected by the pharmacist within 24 hours of admission. METHODS This study was conducted at a tertiary care hospital in a lower middle-income country. Data were gathered from two different sources. The first source involved retrospective data obtained from the Quality and Patient Safety Department (QPSD) of the hospital, consisting of records from 8776 patients between 2018 and 2021. The second data source was also retrospective from a quality project initiated by pharmacists at the hospital. Pharmacists collected data from 1105 patients between 2020 and 2021, specifically focusing on medication history and identifying any discrepancies compared with the history documented by physicians. The collected data were then analysed using SPSS V.26. RESULTS The QPSD noted an improvement in physician-led medication reconciliation, with a rise from 32.7% in 2018 to 69.4% in 2021 in CPOE. However, pharmacist-led medication reconciliation identified a 25.4% (n=281/1105) overall discrepancy in the medication history of patients admitted from 2020 to 2021, mainly due to incomplete medication records in the initial assessment forms and CPOE. Physicians missed critical drugs in 4.9% of records; pharmacists identified and updated them. CONCLUSION In a lower middle-income nation where hiring pharmacists to conduct medication reconciliation would be an additional cost burden for hospitals, encouraging physicians to record medication history more precisely would be a more workable method. However, in situations where cost is not an issue, it is recommended to adopt evidence-based practices, such as integrating clinical pharmacists to lead medication reconciliation, which is the gold standard worldwide.
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Affiliation(s)
- Samar Fatima
- Department of Medicine, The Aga Khan University Hospital, Karachi, Pakistan
| | - Ainan Arshad
- Department of Medicine, The Aga Khan University Hospital, Karachi, Pakistan
| | - Amara Zafar
- Department of Medicine, The Aga Khan University Hospital, Karachi, Pakistan
| | - Sana Farrukh
- Department of Community Health Sciences, The Aga Khan University Hospital, Karachi, Pakistan
| | - Anum Rahim
- Department of Community Health Sciences, The Aga Khan University Hospital, Karachi, Pakistan
| | - Saharish Nazar
- Pharmacy, The Aga Khan University Hospital, Karachi, Pakistan
| | - Hasnain Zafar
- Department of Surgery, The Aga Khan University Hospital, Karachi, Pakistan
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Macwan AA, Panda AP, Sondur S, Rath S. Benchmarking institutional geriatric hip fracture management: a prelude to a care quality improvement initiative. Eur J Orthop Surg Traumatol 2024; 34:1571-1580. [PMID: 38305927 DOI: 10.1007/s00590-024-03838-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 01/18/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND Fractures around the hip in older adults have increased in the last two decades, and the numbers are projected to rise over the next 30 years with estimates that half of them will occur in Asia. Proximal hip fractures should be operated within 48 h of injury to prevent poor outcomes. This study aims to benchmark current hip fracture care using quality improvement tools of care structure, care processes, and outcomes in a tertiary care hospital in Eastern India and determine the evidence-practice gaps and barriers to implementing the six best practices that reduce mortality and morbidity in fragility hip fractures. METHODS A total of 101 consecutive patients above 50 years of age with proximal femoral fractures after a trivial fall were included. Patients were divided into two groups: those operated within [Group A] and beyond [Group B] 72 h of admission. Care structure assessment included delays in admission, delay in surgery, and anesthesia risk grading. Care processes included the type of surgery performed and postoperative complications. The primary outcomes were the 30-day and 1-year mortality and the secondary outcomes included the length of stay, mobility at 6 months, return to pre-fracture independence, activity limitations, pressure sores, and readmission to the hospital. RESULTS Group A comprised 26 individuals, and the remaining 75 were in Group B. There were two deaths in Group A as compared to one death in Group B at 30 days; however, there were no new deaths at 1 year in Group A and 14 deaths in Group B (p = 0.187). Group B had lengthier hospital stays, poorer mobility, and higher physical and mental difficulties. No patients had re-operation on the initial fracture. CONCLUSION This study emphasizes the importance of early admission and fast provision of surgical fixation to reduce mortality and morbidity. Benchmarking institutional practices allows for defining the evidence-practice gaps and barriers to best practice implementation. This is an essential step to begin care quality improvement for geriatric patients with proximal femur fragility fractures.
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Affiliation(s)
- Anson Albert Macwan
- Department of Orthopaedics, Kalinga Institute of Medical Sciences, KIIT University, Bhubaneshwar, Odisha, 751024, India
| | - Aditya Prasad Panda
- Department of Orthopaedics, Kalinga Institute of Medical Sciences, KIIT University, Bhubaneshwar, Odisha, 751024, India
| | - Suhas Sondur
- Department of Orthopaedics, Kalinga Institute of Medical Sciences, KIIT University, Bhubaneshwar, Odisha, 751024, India
| | - Santosh Rath
- Department of Orthopaedics, Kalinga Institute of Medical Sciences, KIIT University, Bhubaneshwar, Odisha, 751024, India.
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Bolger LA, O'Riordan N, Allen C. A rapid improvement event: progesterone prescribing in prevention of miscarriage. BMJ Open Qual 2024; 13:e002517. [PMID: 38531628 DOI: 10.1136/bmjoq-2023-002517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 03/02/2024] [Indexed: 03/28/2024] Open
Abstract
A rapid improvement event (RIE) is a standard operational excellence technique that uses team-based problem solving to improve processes. In this study, a RIE was undertaken to improve progesterone prescribing rates for those with a history of miscarriage experiencing vaginal bleeding in early pregnancy. This was on the basis of a recent change in guidelines regarding prescribing in these instances. NICE guidelines changed in November 2021 after Cochrane meta-analysis and the PRISM (Progesterone in Spontaneous Miscarriage) randomised control trial demonstrated a higher incidence of live births in those prescribed vaginal micronised progesterone for threatened miscarriage, when compared with those not prescribed it.A RIE involves a team approach and a standard sequence of events allowing analysis and improvement of a process. Analysis in the form of audit revealed a low progesterone prescribing rate for eligible patients in our unit. Dissection of this problem into its elements revealed a low level of staff knowledge regarding the change in guidelines and a lack of confidence in prescription of progesterone. A plan of actionable events to improve prescribing rates was devised. The updated guidance and local recommendations on appropriate micronised progesterone formulations were presented at hospital Grand Rounds with multidisciplinary attendance. Infographics were displayed in areas visible to stakeholders within the hospital and on the hospital's social media pages. The validity of these educational measures to improve the process was reaudited after 3 months.Progesterone prescribing improved by 48%. Those comfortable with prescribing as per the new guidelines improved from 43% to 78%. A RIE proved to be an effective and efficient approach to collaboration, decision-making and action.
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Affiliation(s)
- Lucy Anne Bolger
- Obstetrics & Gynaecology, National Maternity Hospital, Dublin, Ireland
| | - Nicola O'Riordan
- Obstetrics & Gynaecology, National Maternity Hospital, Dublin, Ireland
| | - Cathy Allen
- Obstetrics & Gynaecology, National Maternity Hospital, Dublin, Ireland
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Bateman N. Effective use of interdisciplinary approaches in healthcare quality: drawing on operations and visual management. BMJ Qual Saf 2024; 33:216-219. [PMID: 38448220 DOI: 10.1136/bmjqs-2023-016947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2024] [Indexed: 03/08/2024]
Affiliation(s)
- Nicola Bateman
- ULSB, University of Leicester, Leicester, Leicestershire, UK
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15
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Lamé G, Liberati EG, Canham A, Burt J, Hinton L, Draycott T, Winter C, Dakin FH, Richards N, Miller L, Willars J, Dixon-Woods M. Why is safety in intrapartum electronic fetal monitoring so hard? A qualitative study combining human factors/ergonomics and social science analysis. BMJ Qual Saf 2024; 33:246-256. [PMID: 37945341 PMCID: PMC10982615 DOI: 10.1136/bmjqs-2023-016144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 09/16/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Problems in intrapartum electronic fetal monitoring with cardiotocography (CTG) remain a major area of preventable harm. Poor understanding of the range of influences on safety may have hindered improvement. Taking an interdisciplinary perspective, we sought to characterise the everyday practice of CTG monitoring and the work systems within which it takes place, with the goal of identifying potential sources of risk. METHODS Human factors/ergonomics (HF/E) experts and social scientists conducted 325 hours of observations and 23 interviews in three maternity units in the UK, focusing on how CTG tasks were undertaken, the influences on this work and the cultural and organisational features of work settings. HF/E analysis was based on the Systems Engineering Initiative for Patient Safety 2.0 model. Social science analysis was based on the constant comparative method. RESULTS CTG monitoring can be understood as a complex sociotechnical activity, with tasks, people, tools and technology, and organisational and external factors all combining to affect safety. Fetal heart rate patterns need to be recorded and interpreted correctly. Systems are also required for seeking the opinions of others, determining whether the situation warrants concern, escalating concerns and mobilising response. These processes may be inadequately designed or function suboptimally, and may be further complicated by staffing issues, equipment and ergonomics issues, and competing and frequently changing clinical guidelines. Practice may also be affected by variable standards and workflows, variations in clinical competence, teamwork and situation awareness, and the ability to communicate concerns freely. CONCLUSIONS CTG monitoring is an inherently collective and sociotechnical practice. Improving it will require accounting for complex system interdependencies, rather than focusing solely on discrete factors such as individual technical proficiency in interpreting traces.
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Affiliation(s)
- Guillaume Lamé
- Laboratoire Génie Industriel, CentraleSupélec, Gif-sur-Yvette, France
- Department of Public Health and Primary Care, THIS Institute (The Healthcare Improvement Studies Institute), University of Cambridge, Cambridge, UK
| | - Elisa Giulia Liberati
- Department of Public Health and Primary Care, THIS Institute (The Healthcare Improvement Studies Institute), University of Cambridge, Cambridge, UK
| | | | - Jenni Burt
- Department of Public Health and Primary Care, THIS Institute (The Healthcare Improvement Studies Institute), University of Cambridge, Cambridge, UK
| | - Lisa Hinton
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | | | - Francesca Helen Dakin
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Natalie Richards
- Department of Public Health and Primary Care, THIS Institute (The Healthcare Improvement Studies Institute), University of Cambridge, Cambridge, UK
| | - Lucy Miller
- University Division of Anaesthesia, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Janet Willars
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Mary Dixon-Woods
- Department of Public Health and Primary Care, THIS Institute (The Healthcare Improvement Studies Institute), University of Cambridge, Cambridge, UK
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16
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Woodward M, Dixon-Woods M, Randall W, Walker C, Hughes C, Blackwell S, Dewick L, Bahl R, Draycott T, Winter C, Ansari A, Powell A, Willars J, Brown IAF, Olsson A, Richards N, Leeding J, Hinton L, Burt J, Maistrello G, Davies C, van der Scheer JW. How to co-design a prototype of a clinical practice tool: a framework with practical guidance and a case study. BMJ Qual Saf 2024; 33:258-270. [PMID: 38124136 PMCID: PMC10982632 DOI: 10.1136/bmjqs-2023-016196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 11/20/2023] [Indexed: 12/23/2023]
Abstract
Clinical tools for use in practice-such as medicine reconciliation charts, diagnosis support tools and track-and-trigger charts-are endemic in healthcare, but relatively little attention is given to how to optimise their design. User-centred design approaches and co-design principles offer potential for improving usability and acceptability of clinical tools, but limited practical guidance is currently available. We propose a framework (FRamework for co-dESign of Clinical practice tOols or 'FRESCO') offering practical guidance based on user-centred methods and co-design principles, organised in five steps: (1) establish a multidisciplinary advisory group; (2) develop initial drafts of the prototype; (3) conduct think-aloud usability evaluations; (4) test in clinical simulations; (5) generate a final prototype informed by workshops. We applied the framework in a case study to support co-design of a prototype track-and-trigger chart for detecting and responding to possible fetal deterioration during labour. This started with establishing an advisory group of 22 members with varied expertise. Two initial draft prototypes were developed-one based on a version produced by national bodies, and the other with similar content but designed using human factors principles. Think-aloud usability evaluations of these prototypes were conducted with 15 professionals, and the findings used to inform co-design of an improved draft prototype. This was tested with 52 maternity professionals from five maternity units through clinical simulations. Analysis of these simulations and six workshops were used to co-design the final prototype to the point of readiness for large-scale testing. By codifying existing methods and principles into a single framework, FRESCO supported mobilisation of the expertise and ingenuity of diverse stakeholders to co-design a prototype track-and-trigger chart in an area of pressing service need. Subject to further evaluation, the framework has potential for application beyond the area of clinical practice in which it was applied.
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Affiliation(s)
- Matthew Woodward
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Mary Dixon-Woods
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | | | | | | | | | - Louise Dewick
- Royal College of Obstetricians and Gynaecologists, London, UK
| | - Rachna Bahl
- Royal College of Obstetricians and Gynaecologists, London, UK
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Tim Draycott
- Royal College of Obstetricians and Gynaecologists, London, UK
- North Bristol NHS Trust, Westbury on Trym, UK
| | | | - Akbar Ansari
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Alison Powell
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Janet Willars
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Imogen A F Brown
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Annabelle Olsson
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Natalie Richards
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Joann Leeding
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Lisa Hinton
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Jenni Burt
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | | | | | - Jan W van der Scheer
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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17
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Gillespie BM, Ziemba JB. Lost in translation: does measuring 'adherence' to the Surgical Safety Checklist indicate true implementation fidelity? BMJ Qual Saf 2024; 33:209-211. [PMID: 38191563 DOI: 10.1136/bmjqs-2023-016617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2023] [Indexed: 01/10/2024]
Affiliation(s)
- Brigid M Gillespie
- National Health and Medical Research Council Centre of Research Excellence in Wiser Wound Care, Menzies Health Institute Queensland & School of Nursing & Midwifery, Griffith University, Gold Coast, Queensland, Australia
- Gold Coast University Hospital, Gold Coast Health, Gold Coast, Queensland, Australia
| | - Justin Bradley Ziemba
- Department of Clinical Effectiveness and Quality Improvement, University of Pennsylvania Health System, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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18
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Lahnaoui O, Houmada A, Benkabbou A, Ghannam A, Al Ahmadi B, Belkhadir Z, Mohsine R, Souadka A, Majbar MA. Enhancing patient safety: a system-based analysis of morbidity and mortality conferences in managing postoperative bleeding following gastric and pancreatic cancer surgery. BMJ Open Qual 2024; 13:e002657. [PMID: 38485113 PMCID: PMC10941144 DOI: 10.1136/bmjoq-2023-002657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 02/28/2024] [Indexed: 03/17/2024] Open
Abstract
Morbidity and mortality conferences (MMCs) have evolved beyond their traditional educational role to become instrumental in enhancing patient safety. System-based MMCs offer a unique perspective on patient safety by dissecting systemic factors contributing to adverse events. This paper reviews the impact of MMC in managing postoperative bleeding after gastric and pancreatic cancer surgery, within the constraints of limited resources. The study conducted at the National Institute of Oncology in Rabat, Morocco, analysed 18 MMC of haemorrhage following gastric and pancreatic surgeries and allowed to identify two patterns of cumulative factors contributing to adverse events. The first one relates to organisational issues and the second to postoperative management. Fifteen recommendations of improvement emerged from MMC addressing elements of these patterns with an implementation rate of 53.3%.
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Affiliation(s)
- Oumayma Lahnaoui
- National Institute of Oncology - Surgical Oncology Department, Mohammed V University in Rabat, Rabat, Morocco
| | - Amina Houmada
- National Institute of Oncology - Surgical Oncology Department, Mohammed V University in Rabat, Rabat, Morocco
| | - Amine Benkabbou
- National Institute of Oncology - Surgical Oncology Department, Mohammed V University in Rabat, Rabat, Morocco
| | - Abdelillah Ghannam
- National Institute of Oncology - Intensive Care Department, Mohammed V University in Rabat, Rabat, Morocco
| | - Brahim Al Ahmadi
- National Institute of Oncology - Intensive Care Department, Mohammed V Souissi University, Rabat, Morocco
| | - Zakaria Belkhadir
- National Institute of Oncology - Intensive Care Department, Mohammed V University in Rabat, Rabat, Morocco
| | - Raouf Mohsine
- National Institute of Oncology - Surgical Oncology Department, Mohammed V University in Rabat, Rabat, Morocco
| | - Amine Souadka
- National Institute of Oncology - Surgical Oncology Department, Mohammed V University in Rabat, Rabat, Morocco
| | - Mohammed Anass Majbar
- National Institute of Oncology - Surgical Oncology Department, Mohammed V University in Rabat, Rabat, Morocco
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Bayisa G, Gonfaa L, Badasa K, Dugasa N, Abebe M, Deressa H, Teshoma Regassa M, Takele A, Tilahun T. Improving medical record completeness at Wallaga University Referral Hospital: a multidimensional quality improvement project. BMJ Open Qual 2024; 13:e002665. [PMID: 38458759 DOI: 10.1136/bmjoq-2023-002665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 01/31/2024] [Indexed: 03/10/2024] Open
Abstract
BACKGROUND Appropriately documented medical records enhance coordination, patient outcomes and clinical research. OBJECTIVE The aim of this project was to improve Wallaga University Referral Hospital's (WURH) medical record completeness rate from 53% to 80% from 1 January 2023 to 31 August 2023. METHODS A hospital-based interventional study was conducted at WURH. The Plan-Do-Study-Act cycle was used to test change ideas. A fishbone diagram and a driver diagram were used to identify root causes and address them. Key interventions consisted of supportive supervision, developing and distributing standardised formats, orientation for staff, establishing a chart audit team and assigning data owners. RESULT On the completion of the project, the overall implementation of inpatient medical record completeness increased from 53% to 82%. This improvement varies from department-to-department. It increased from 51% to 79%, 53% to 79%, 46% to 81% and 64% to 91% in the departments of internal medicine, paediatrics, obstetrics and gynaecology and surgery, respectively. The project brought improvements in the completeness of physician notes (84% to 100%), physician order sheet (54% to 84%), nursing care plan (26% to 69%), admission sheet (76% to 98%), discharge summary (94% to 98%), progress note (38% to 91%), medication administration (80% to 100%), appropriate attachment of documents (78% to 93%) and documentation of vital signs (50% to 100%). CONCLUSION AND RECOMMENDATION The rate of medical record completeness was significantly improved in the study area. This was achieved through the application of multidimensional change ideas related to health professionals, supplies, health management information systems and leadership. However, in some of the parameters, the national targets were not met. Therefore, we recommend providing regular technical updates, conducting frequent chart audits and providing supportive supervision for the enhancement of medical record completeness. It is also advisable for the hospital management to work on its sustainability.
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Affiliation(s)
- Gedefa Bayisa
- Quality Assurance, Nursing and Midwifery, Wallaga University Referral Hospital, Nekemte, Ethiopia
| | - Lammii Gonfaa
- Department of Obstetrics and Gynecology, Wollega University Institute of Health Sciences, Nekemte, Ethiopia
| | - Ketema Badasa
- Quality Assurance, Nursing and Midwifery, Wallaga University Referral Hospital, Nekemte, Ethiopia
| | - Nemomsa Dugasa
- Quality Assurance, Nursing and Midwifery, Wallaga University Referral Hospital, Nekemte, Ethiopia
| | - Mulugeta Abebe
- Quality Assurance, Nursing and Midwifery, Wallaga University Referral Hospital, Nekemte, Ethiopia
| | - Habtamu Deressa
- Inpatient Nursing Service, Wallaga University Referral Hospital, Nekemte, Ethiopia
| | | | - Amsalu Takele
- Department of Surgery, Wollega University Institute of Health Sciences, Nekemte, Ethiopia
| | - Temesgen Tilahun
- Department of Obstetrics and Gynecology, Wollega University Institute of Health Sciences, Nekemte, Ethiopia
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Panganiban JMS, Loreche AM, De Mesa RYH, Camiling-Alfonso R, Fabian NMC, Dans LF, Galingana CLT, Lopez JFE, Casile RU, Aquino MRN, Rey MP, Sanchez JT, Javelosa MAU, Tan-Lim CSC, Marfori JRA, Paterno RP, Dans AL. Promoting equitable and patient-centred care: an analysis of patient satisfaction in urban, rural and remote primary care sites in the Philippines. BMJ Open Qual 2024; 13:e002483. [PMID: 38448041 PMCID: PMC10916135 DOI: 10.1136/bmjoq-2023-002483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 02/28/2024] [Indexed: 03/08/2024] Open
Abstract
OBJECTIVES This study measured changes in patient satisfaction levels before and after the introduction of primary care system strengthening interventions in urban, rural, and remote sites in the Philippines. METHODS A previously validated 16-item questionnaire was distributed to 200 patients per site before implementation of interventions and to a different set of 200 patients 1 year after implementation. We compared the percentage change in highly satisfied patients per site before and after implementing interventions using a two-proportion Z-test. RESULTS The urban site had a significant increase in patient satisfaction in 13 survey items, which corresponded to the domains of healthcare availability, service efficiency, technical competency and health communication. The rural site had a significant increase in six survey items, which corresponded to the domains of service efficiency, environment, location, health communication and handling. The remote site had a decrease in patient satisfaction in 10 survey items, with a significant increase in only 4 items under the domains of healthcare availability and handling. CONCLUSION Our findings support the 'inverse equity hypothesis', where well-resourced urban communities quickly adopt complex health interventions while rural and remote settings experience delays in effectively meeting patient needs and system demands. Extended intervention periods and targeted strategies may be necessary to impact patient satisfaction in underserved areas considerably.
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Affiliation(s)
| | - Arianna Maever Loreche
- National Clinical Trials and Translation Center, University of the Philippines Manila, Manila, Philippines
| | - Regine Ynez H De Mesa
- Center for Integrative and Development Studies, University of the Philippines Diliman, Quezon City, Philippines
| | - Romelei Camiling-Alfonso
- Center for Integrative and Development Studies, University of the Philippines Diliman, Quezon City, Philippines
| | - Noleen Marie C Fabian
- Center for Integrative and Development Studies, University of the Philippines Diliman, Quezon City, Philippines
- University of the East Ramon Magsaysay Memorial Medical Center Inc, Quezon City, Philippines
| | - Leonila F Dans
- Center for Integrative and Development Studies, University of the Philippines Diliman, Quezon City, Philippines
- Department of Pediatrics, Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Cara Lois T Galingana
- Center for Integrative and Development Studies, University of the Philippines Diliman, Quezon City, Philippines
| | - Johanna Faye E Lopez
- Center for Integrative and Development Studies, University of the Philippines Diliman, Quezon City, Philippines
| | - Ray U Casile
- Center for Integrative and Development Studies, University of the Philippines Diliman, Quezon City, Philippines
| | - Maria Rhodora N Aquino
- Center for Integrative and Development Studies, University of the Philippines Diliman, Quezon City, Philippines
| | - Mia P Rey
- Department of Accounting and Finance, Cesar E.A. Virata School of Business, University of the Philippines Diliman, Quezon City, Philippines
| | - Josephine T Sanchez
- Center for Integrative and Development Studies, University of the Philippines Diliman, Quezon City, Philippines
| | - Mark Anthony U Javelosa
- Department of Clinical Epidemiology, University of the Philippines Manila, Manila, Philippines
| | | | - Jose Rafael A Marfori
- Center for Integrative and Development Studies, University of the Philippines Diliman, Quezon City, Philippines
- Department of Clinical Epidemiology, University of the Philippines Manila, Manila, Philippines
| | - Ramon Pedro Paterno
- Center for Integrative and Development Studies, University of the Philippines Diliman, Quezon City, Philippines
| | - Antonio L Dans
- Center for Integrative and Development Studies, University of the Philippines Diliman, Quezon City, Philippines
- National Institutes of Health, University of the Philippines Manila, Manila, Philippines
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Duclos A. Pragmatic trials are needed to assess the effectiveness of enhanced recovery after surgery protocols on patient safety. BMJ Qual Saf 2024:bmjqs-2023-016966. [PMID: 38429103 DOI: 10.1136/bmjqs-2023-016966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2024] [Indexed: 03/03/2024]
Affiliation(s)
- Antoine Duclos
- Research on Healthcare Performance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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22
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Ravat Z, Sinha A, Jellinek A, Page N. AMU patient list generation: from junior scribe to junior doctor. BMJ Open Qual 2024; 13:e002421. [PMID: 38429062 PMCID: PMC10910655 DOI: 10.1136/bmjoq-2023-002421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 02/20/2024] [Indexed: 03/03/2024] Open
Abstract
This quality improvement project (QIP) aimed to assess the impact of automating patient list generation on the acute medical unit (AMU) at Sandwell and West Birmingham Hospitals NHS Trust. The AMU patient list categorises patients requiring 'clerking', 'post-take' (PTWR) and 'post-post-take' (PPTWR) for the morning ward round. During weekdays, this list need only include the patients in AMU. For weekends, this list must include 'outliers', that is, patients transferred to different wards (which may lack resident medical teams over the weekends) but still requiring PTWR/PPTWR. The list is created by the junior doctor on their night shift, a daily necessity due to the high AMU patient turnover.A pilot study, followed by three complete 'plan-do-study-act' (PDSA) cycles, was conducted over 2021/2022. Cycle 1 (pre-intervention) and cycle 2 (post-intervention) assessed the impact of the generator on weekdays. This was adapted for the weekend over cycles 2 and 3. The process measure assessed was the time taken for list generation. The outcome measure was the total number of patients clerked per night. The balancing measure was doctors' attitudes.The intervention reduced the time taken for list generation by an average of 44.3 min (66.3%) during weekdays and 37.8 min (42%) during weekends. Run charts demonstrated significance for the reduction in weekday list generation time. Both weekdays (63.5% decrease, p<0.00001) and weekends (50.5% decrease, p=0.0007) had significant reductions in total negative attitudes. Both weekdays and weekends had 'time-consuming' as the most frequently selected attitude pre-intervention, whereas 'easy to make' was most frequently selected post-intervention. Some junior doctors reported the generator enabled clerking of extra patients, supported by non-significant increases in the averages for this outcome.This QIP demonstrates how the automation of labour-intensive administrative tasks results in notable time-saving outcomes. Thereby improving doctor attitudes and well-being, and facilitating the delivery of quality patient care.
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Affiliation(s)
- Zahra Ravat
- Acute Medical Unit, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Amil Sinha
- Acute Medical Unit, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Alistair Jellinek
- Acute Medical Unit, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Nigel Page
- Acute Medical Unit, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
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Berg M, Berg U, Mapatano E, Mukwege D. Caesarean section rate reduced by a redesigned birthing room. Results of a quality improvement intervention at a hospital in Democratic Republic of Congo. Sex Reprod Healthc 2024; 39:100925. [PMID: 38056384 DOI: 10.1016/j.srhc.2023.100925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 11/08/2023] [Accepted: 11/20/2023] [Indexed: 12/08/2023]
Abstract
OBJECTIVE To evaluate the influence of a new birthing room at a tertiary hospital in eastern Democratic Republic of Congo (DRC), on the caesarean section (CS) rate in women classified as Robson group 1, i.e., nulliparous women at term with spontaneous onset of labour of one foetus in cephalic presentation. METHOD As part of quality improvement interventions, a new birthing room designed to promote person-centredness was constructed at the labour ward at Panzi General Referral Hospital in DRC. In a quasi-experimental study on women classified as Robson 1, a comparison was performed between the group being cared for in the new birthing room and the group being cared for in the general birthing room. The main outcome measure was CS rate. RESULTS In the new person-centred birthing room, the CS rate was 17.1 % versus 28.4 % in women cared for in the general birthing room (p-value 0.001). There was also a higher presence of accompanying persons (p-value < 0.0001) and less use of synthetic oxytocin for the augmentation of labour (p-value 0.024). No difference in fear and childbirth experience was identified between women in the two rooms. CONCLUSION The results demonstrate that it is possible, in a low-income country as the Democratic Republic of Congo, to reduce the CS rate in women classified as Robson 1 by adapting the birthing environment to be more person-centred, without compromising other obstetric and neonatal outcomes.
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Affiliation(s)
- M Berg
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Arvid Wallgrens backe 1, 413 46 Gothenburg, Sweden; Faculty of Medicine and Community Health, Evangelical University in Africa, Bukavu, Democratic Republic of Congo; Panzi General Referral Hospital, Bukavu, Democratic Republic of Congo.
| | - U Berg
- Faculty of Medicine and Community Health, Evangelical University in Africa, Bukavu, Democratic Republic of Congo; Panzi General Referral Hospital, Bukavu, Democratic Republic of Congo; Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - E Mapatano
- Faculty of Medicine and Community Health, Evangelical University in Africa, Bukavu, Democratic Republic of Congo; Panzi General Referral Hospital, Bukavu, Democratic Republic of Congo
| | - D Mukwege
- Faculty of Medicine and Community Health, Evangelical University in Africa, Bukavu, Democratic Republic of Congo; Panzi General Referral Hospital, Bukavu, Democratic Republic of Congo
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Devlin MK, McIntyre NJ, Ramer MD, Kwon YH, Nicholson JM, Mrkobrada M, Kronick J, Calvin JE, Spicer E. Applying the lessons of design thinking: a unique programme of care for acutely unwell, community-dwelling COVID-19 patients. BMJ Open Qual 2024; 13:e002500. [PMID: 38413092 PMCID: PMC10900416 DOI: 10.1136/bmjoq-2023-002500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 02/11/2024] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND The COVID-19 pandemic limited access to primary care and in-person assessments requiring healthcare providers to re-envision care delivery for acutely unwell outpatients. Design thinking methodology has the potential to support the robust evolution of a new clinical model. AIM To demonstrate how design thinking methodology can rapidly and rigorously create and evolve a safe, timely, equitable and patient-centred programme of care, and to share valuable lessons for effective implementation of design thinking solutions to address complex problems. METHOD We describe how design thinking methodology was employed to create a new clinical model of care. Using the example of a novel telemedicine programme to support acutely unwell, community-dwelling COVID-19-positive patients called the London Urgent COVID-19 Care Clinic (LUC3), we show how continuous quality outcomes (safety, timeliness, equity and patient-centredness), as well as patient experience survey responses, can drive iterative changes in programme delivery. RESULTS The inspiration phase identified four key needs for this patient population: monitoring COVID-19 signs and symptoms; self-managing COVID-19 symptoms; managing other comorbidities in the setting of COVID-19; and escalating care as needed. Guided by these needs, a cross-disciplinary stakeholder group was engaged in the ideation and implementation phases to create a unique and comprehensive telemedicine programme (LUC3). During the implementation phase, LUC3 assessed 2202 community-based patients diagnosed with acute COVID-19; the collected quality outcomes and end-user feedback led to evolution of programme delivery. CONCLUSION Design thinking methodology provided an essential framework and valuable lessons for the development of a safe, equitable, timely and patient-centred telemedicine care programme. The lessons learnt here-the importance of inclusive collaboration, using empathy to guide equity-focused interventions, leveraging continuous metrics to drive iteration and aiming for good-if-not-perfect plans-can serve as a road map for using design thinking for targeted healthcare problems.
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Affiliation(s)
- Megan K Devlin
- Division of Infectious Diseases, Department of Medicine, Western University, London, Ontario, Canada
- Infectious Diseases Care Program, St Joseph's Health Care London, London, Ontario, Canada
| | - Natasha J McIntyre
- Centre for Quality, Innovation and Safety, Western University, London, Ontario, Canada
| | - Matthew D Ramer
- Faculty of Health Sciences and Wellness, Humber College Institute of Technology and Advanced Learning, Toronto, Ontario, Canada
| | - Young Han Kwon
- Centre for Quality, Innovation and Safety, Western University, London, Ontario, Canada
| | - J Michael Nicholson
- Division of Respirology, Department of Medicine, Western University, London, Ontario, Canada
| | - Marko Mrkobrada
- Division of General Internal Medicine, Department of Medicine, Western University, London, Ontario, Canada
| | - Jami Kronick
- Western University Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - James E Calvin
- Centre for Quality, Innovation and Safety, Western University, London, Ontario, Canada
- Department of Medicine, Western University, London, Ontario, Canada
| | - Erin Spicer
- Centre for Quality, Innovation and Safety, Western University, London, Ontario, Canada
- Division of General Internal Medicine, Department of Medicine, Western University, London, Ontario, Canada
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van der Linde M, Salet N, van Leeuwen N, Lingsma HF, Eijkenaar F. Between-hospital variation in indicators of quality of care: a systematic review. BMJ Qual Saf 2024:bmjqs-2023-016726. [PMID: 38395610 DOI: 10.1136/bmjqs-2023-016726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 01/17/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Efforts to mitigate unwarranted variation in the quality of care require insight into the 'level' (eg, patient, physician, ward, hospital) at which observed variation exists. This systematic literature review aims to synthesise the results of studies that quantify the extent to which hospitals contribute to variation in quality indicator scores. METHODS Embase, Medline, Web of Science, Cochrane and Google Scholar were systematically searched from 2010 to November 2023. We included studies that reported a measure of between-hospital variation in quality indicator scores relative to total variation, typically expressed as a variance partition coefficient (VPC). The results were analysed by disease category and quality indicator type. RESULTS In total, 8373 studies were reviewed, of which 44 met the inclusion criteria. Casemix adjusted variation was studied for multiple disease categories using 144 indicators, divided over 5 types: intermediate clinical outcomes (n=81), final clinical outcomes (n=35), processes (n=10), patient-reported experiences (n=15) and patient-reported outcomes (n=3). In addition to an analysis of between-hospital variation, eight studies also reported physician-level variation (n=54 estimates). In general, variation that could be attributed to hospitals was limited (median VPC=3%, IQR=1%-9%). Between-hospital variation was highest for process indicators (17.4%, 10.8%-33.5%) and lowest for final clinical outcomes (1.4%, 0.6%-4.2%) and patient-reported outcomes (1.0%, 0.9%-1.5%). No clear pattern could be identified in the degree of between-hospital variation by disease category. Furthermore, the studies exhibited limited attention to the reliability of observed differences in indicator scores. CONCLUSION Hospital-level variation in quality indicator scores is generally small relative to residual variation. However, meaningful variation between hospitals does exist for multiple indicators, especially for care processes which can be directly influenced by hospital policy. Quality improvement strategies are likely to generate more impact if preceded by level-specific and indicator-specific analyses of variation, and when absolute variation is also considered. PROSPERO REGISTRATION NUMBER CRD42022315850.
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Affiliation(s)
| | - Nèwel Salet
- Erasmus Universiteit Rotterdam, Erasmus School of Health Policy and Management, Rotterdam, The Netherlands
| | | | - Hester F Lingsma
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | - Frank Eijkenaar
- Erasmus Universiteit Rotterdam, Erasmus School of Health Policy and Management, Rotterdam, The Netherlands
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Leon C, Hogan H, Jani YH. Identifying and mapping measures of medication safety during transfer of care in a digital era: a scoping literature review. BMJ Qual Saf 2024; 33:173-186. [PMID: 37923372 PMCID: PMC10894843 DOI: 10.1136/bmjqs-2022-015859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 10/04/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Measures to evaluate high-risk medication safety during transfers of care should span different safety dimensions across all components of these transfers and reflect outcomes and opportunities for proactive safety management. OBJECTIVES To scope measures currently used to evaluate safety interventions targeting insulin, anticoagulants and other high-risk medications during transfers of care and evaluate their comprehensiveness as a portfolio. METHODS Embase, Medline, Cochrane and CINAHL databases were searched using scoping methodology for studies evaluating the safety of insulin, anticoagulants and other high-risk medications during transfer of care. Measures identified were extracted into a spreadsheet, collated and mapped against three frameworks: (1) 'Key Components of an Ideal Transfer of Care', (2) work systems, processes and outcomes and (3) whether measures captured past harms, events in real time or areas of concern. The potential for digital health systems to support proactive measures was explored. RESULTS Thirty-five studies were reviewed with 162 measures in use. Once collated, 29 discrete categories of measures were identified. Most were outcome measures such as adverse events. Process measures included communication and issue identification and resolution. Clinic enrolment was the only work system measure. Twenty-four measures captured past harm (eg, adverse events) and six indicated future risk (eg, patient feedback for organisations). Two real-time measures alerted healthcare professionals to risks using digital systems. No measures were of advance care planning or enlisting support. CONCLUSION The measures identified are insufficient for a comprehensive portfolio to assess safety of key medications during transfer of care. Further measures are required to reflect all components of transfers of care and capture the work system factors contributing to outcomes in order to support proactive intervention to reduce unwanted variation and prevent adverse outcomes. Advances in digital technology and its employment within integrated care provide opportunities for the development of such measures.
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Affiliation(s)
- Catherine Leon
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Helen Hogan
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Yogini H Jani
- Department of Practice and Policy, University College London School of Pharmacy, London, UK
- Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust, London, UK
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Browne J, Franklin BD, Thomas EJ, Marang-van de Mheen PJ. Our mission and how we hope to move the field forward: statement from the BMJ Quality & Safety senior editorial team 2023. BMJ Qual Saf 2024; 33:141-144. [PMID: 38124225 DOI: 10.1136/bmjqs-2023-016811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2023] [Indexed: 12/23/2023]
Affiliation(s)
- John Browne
- School of Public Health, University College Cork, Cork, Ireland
| | - Bryony Dean Franklin
- Director, Centre for Medication Safety and Service Quality, Imperial College Healthcare NHS Trust, London, UK
- Department of Practice and Policy, UCL School of Pharmacy, London, UK
| | - Eric J Thomas
- Internal Medicine, University of Texas John P and Katherine G McGovern Medical School, Houston, Texas, USA
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Affiliation(s)
- Karen B Born
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Wendy Levinson
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Emma Vaux
- Department of Renal Medicine, Royal Berkshire Hospital NHS Foundation Trust, Reading, UK
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Armstrong N, Sutton E, Chew S, Tarrant C. Identifying patients with additional needs isn't enough to improve care: harnessing the benefits and avoiding the pitfalls of classification. BMJ Qual Saf 2024; 33:152-155. [PMID: 38135496 DOI: 10.1136/bmjqs-2023-016809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2023] [Indexed: 12/24/2023]
Affiliation(s)
- Natalie Armstrong
- Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - Elizabeth Sutton
- Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - Sarah Chew
- Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - Carolyn Tarrant
- Department of Population Health Sciences, University of Leicester, Leicester, UK
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30
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Desveaux L, Ivers N. Practice or perfect? Coaching for a growth mindset to improve the quality of healthcare. BMJ Qual Saf 2024:bmjqs-2023-016456. [PMID: 38355297 DOI: 10.1136/bmjqs-2023-016456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 01/28/2024] [Indexed: 02/16/2024]
Affiliation(s)
- Laura Desveaux
- Trillium Health Partners Institute for Better Health, Mississauga, Ontario, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Noah Ivers
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, Ontario, Canada
- Department of Family & Community Medicine, University of Toronto, Toronto, Ontario, Canada
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Robinson Smith P, Richardson A, Macdougall L, Cross E, Davison S, Knowles V. Changing the liver transplant assessment process from inpatient to a day-case and outpatient approach to reduce inpatient bed utlisation. BMJ Open Qual 2024; 13:e002693. [PMID: 38351032 PMCID: PMC10868252 DOI: 10.1136/bmjoq-2023-002693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 01/25/2024] [Indexed: 02/16/2024] Open
Abstract
The liver transplant assessment process involves a complex set of tests and clinical reviews to determine suitability for liver transplantation. We had an assessment process involving a 3-day inpatient stay and often experienced difficulties admitting patients to the prebooked bed due to a lack of inpatient bed availability.We aimed to change the process from a 3-day and 2-night inpatient stay to a 1-day day-case stay to reduce the demand for inpatient beds.Planning the new assessment process involved negotiations with many department staff to establish prebooked timeslots in 1 day. The improvement project was tested and refined through Plan-Do-Study-Act cycles. The liver transplant assessment team used their established once-a-week meeting to learn what went well and to agree on revisions to the process for further testing. The process involved several adaptations, such as the removal and changing of individual time slots, reinforcement of early notification once patients had finished their tests and scheduling a separate outpatient appointment to provide time for junior doctor clerking and blood tests.The new day-case and outpatient coordinated liver transplant assessment process resulted in a reduction of inpatient hospital bed utilisation from an average of 257-20 inpatient bed days per annum. This reduction in inpatient bed utilisation was maintained for 3 years with a similar level of patient satisfaction. The cost avoidance was calculated at £381.96 per patient, which is a 63% reduction in cost. Assuming an average number of patients being assessed per annum of 110, this would result in an average cost avoidance of £42 016 per annum. The carbon footprint was calculated with an average reduction per patient from 618 kilograms of carbon dioxide equivalent (kgCO2e) to 179 kgCO2e.This project has highlighted how to change a complex inpatient assessment process to an alternative day-case and outpatient approach and could be considered useful learning for other inpatient assessment services, not just liver transplantation.
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Affiliation(s)
| | - Annette Richardson
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Louise Macdougall
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Ellice Cross
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Siobhan Davison
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Vanessa Knowles
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
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Azangou-Khyavy M, Ghasemi E, Rezaei N, Khanali J, Kolahi AA, Malekpour MR, Heidari-Foroozan M, Nasserinejad M, Mohammadi E, Abbasi-Kangevari M, Ghamari SH, Ebrahimi N, Koolaji S, Khosravifar M, Fateh SM, Larijani B, Farzadfar F. Global, regional, and national quality of care index of cervical and ovarian cancer: a systematic analysis for the global burden of disease study 1990-2019. BMC Womens Health 2024; 24:69. [PMID: 38273304 PMCID: PMC10809627 DOI: 10.1186/s12905-024-02884-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 01/04/2024] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND AND OBJECTIVE Cervical cancer is the most preventable and ovarian cancer is the most lethal gynecological cancer. However, in the world, there are disparities in health care performances resulting in differences in the burden of these cancers. The objective of this study was to compare the health-system quality of care and inequities for these cancers using the Quality of Care Index (QCI). MATERIAL AND METHODS The 1990-2019 data of the Global Burden of Disease (GBD) was analyzed to extract rates of incidence, prevalence, mortality, Disability-Adjusted Life Years (DALYs), Years of Life Lost (YLL), and Years of healthy life lost due to disability (YLD) of cervical and ovarian cancer. Four indices were developed as a proxy for the quality of care using the above-mentioned rates. Thereafter, a Principal Components Analysis (PCA) was applied to construct the Quality of Care Index (QCI) as a summary measure of the developed indices. RESULTS The incidence of cervical cancer decreased from 1990 to 2019, whereas the incidence of ovarian cancer increased between these years. However, the mortality rate of both cancers decreased in this interval. The global age-standardized QCI for cervical cancer and ovarian cancer were 43.1 and 48.5 in 1990 and increased to 58.5 and 58.4 in 2019, respectively. QCI for cervical cancer and ovarian cancer generally decreased with aging, and different age groups had inequitable QCIs. Higher-income countries generally had higher QCIs for both cancers, but exceptions were also observed. CONCLUSIONS Uncovering disparities in cervical and ovarian cancer care across locations, Socio-Demographic Index levels, and age groups necessitate urgent improvements in healthcare systems for equitable care. These findings underscore the need for targeted interventions and prompt future research to explore root causes and effective strategies for narrowing these gaps.
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Affiliation(s)
- Mohammadreza Azangou-Khyavy
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, No. 10, Al-E-Ahmad and Chamran Highway Intersection, Tehran, Iran
- Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Erfan Ghasemi
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, No. 10, Al-E-Ahmad and Chamran Highway Intersection, Tehran, Iran
| | - Negar Rezaei
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, No. 10, Al-E-Ahmad and Chamran Highway Intersection, Tehran, Iran
| | - Javad Khanali
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, No. 10, Al-E-Ahmad and Chamran Highway Intersection, Tehran, Iran
- Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali-Asghar Kolahi
- Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad-Reza Malekpour
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, No. 10, Al-E-Ahmad and Chamran Highway Intersection, Tehran, Iran
| | - Mahsa Heidari-Foroozan
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, No. 10, Al-E-Ahmad and Chamran Highway Intersection, Tehran, Iran
- Student Research Committee, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maryam Nasserinejad
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, No. 10, Al-E-Ahmad and Chamran Highway Intersection, Tehran, Iran
| | - Esmaeil Mohammadi
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, No. 10, Al-E-Ahmad and Chamran Highway Intersection, Tehran, Iran
| | - Mohsen Abbasi-Kangevari
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, No. 10, Al-E-Ahmad and Chamran Highway Intersection, Tehran, Iran
- Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyyed-Hadi Ghamari
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, No. 10, Al-E-Ahmad and Chamran Highway Intersection, Tehran, Iran
- Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Narges Ebrahimi
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, No. 10, Al-E-Ahmad and Chamran Highway Intersection, Tehran, Iran
| | - Sogol Koolaji
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, No. 10, Al-E-Ahmad and Chamran Highway Intersection, Tehran, Iran
| | - Mina Khosravifar
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, No. 10, Al-E-Ahmad and Chamran Highway Intersection, Tehran, Iran
| | - Sahar Mohammadi Fateh
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, No. 10, Al-E-Ahmad and Chamran Highway Intersection, Tehran, Iran
| | - Bagher Larijani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Farshad Farzadfar
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, No. 10, Al-E-Ahmad and Chamran Highway Intersection, Tehran, Iran.
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.
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Karvonen KL, Bardach NS. Making lemonade out of lemons: an approach to combining variable race and ethnicity data from hospitals for quality and safety efforts. BMJ Qual Saf 2024; 33:74-77. [PMID: 37714699 DOI: 10.1136/bmjqs-2023-016438] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2023] [Indexed: 09/17/2023]
Affiliation(s)
- Kayla L Karvonen
- Pediatrics, UCSF, San Francisco, California, USA
- Preterm Birth Initiative, UCSF, San Francisco, California, USA
| | - Naomi S Bardach
- Pediatrics, UCSF, San Francisco, California, USA
- Philip R Lee Institute of Health Policy Studies, UCSF, San Francisco, California, USA
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Newhouse R, Cullimore V, Hotton E, Maxwell H, Jones E, Morrison J. Mixed methods study of attitudes on location of gynaecological oncology outpatient care: a patient and healthcare professional questionnaire. BMJ Open Qual 2024; 13:e002539. [PMID: 38232984 PMCID: PMC10806580 DOI: 10.1136/bmjoq-2023-002539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 01/07/2024] [Indexed: 01/19/2024] Open
Abstract
OBJECTIVE Gynaecological oncology place of care is often based on evolution of services, along historical professional boundaries, rather than user needs or preferences. We aimed to assess existing evidence, gather views of patients in the UK on their preferred place of outpatient care for gynaecological malignancies and evaluate alignment with preferences of healthcare professionals (HCP). METHODS We performed a mixed methods study, including a scoping review, a patient survey and a healthcare practitioner questionnaire. We collected quantitative and qualitative data, performing content analysis to determine current practice and impact on patients. RESULTS No studies were identified in our scoping review. We received responses from 159 patients and 54 gynaecological oncology HCPs. There was a strong preference for a dedicated gynaecological oncology setting (89% somewhat or very happy) (p<0.0001). Fifty-three percent of patients were somewhat or very unhappy to have care colocated with general obstetrics and gynaecology services. Specifically, two key themes were identified through content analysis of qualitative data from patients: 'environment and getting this right is vital'; and 'our cancer should be the priority'. HCPs underestimated the strong patient preference to be seen in dedicated units. Of those who see patients within general obstetrics and gynaecology, only 50% said patients were seen at separate times/locations from obstetric patients. CONCLUSION This study demonstrates the significant impact of place of care on gynaecological oncology patients, which may be underestimated by HCPs.
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Affiliation(s)
- Rebecca Newhouse
- Department of Gynaecological Oncology, GRACE Centre, Somerset NHS Foundation Trust, Taunton, Somerset, UK
- Obstetrics and Gynaecology, Gloucestershire Health and Care NHS Foundation Trust, Gloucester, Gloucestershire, UK
| | - Victoria Cullimore
- Obstetrics and Gynaecology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Emily Hotton
- Women and Children's Research, North Bristol NHS Trust Southmead Hospital, Bristol, UK
| | - Hilary Maxwell
- Women's Health Department, Dorset County Hospital NHS Foundation Trust, Dorchester, Dorset, UK
| | - Eleanor Jones
- Department of Obstetrics and Gynaecology, Saint Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
- Gynaecological Oncology Research Group, Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Peaches Womb Cancer Trust, Manchester, UK
| | - Jo Morrison
- Department of Gynaecological Oncology, GRACE Centre, Somerset NHS Foundation Trust, Taunton, Somerset, UK
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Sayer NA, Maieritsch KP, Yamokoski CA, Orazem RJ, Clothier BA, Noorbaloochi S. Evaluation of implementation facilitation integrated into a national mentoring programme to improve access to evidence-based psychotherapy for post-traumatic stress disorder within the veterans health administration: a quality improvement report. BMJ Open Qual 2024; 13:e002449. [PMID: 38216294 PMCID: PMC10806576 DOI: 10.1136/bmjoq-2023-002449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 12/07/2023] [Indexed: 01/14/2024] Open
Abstract
Despite the resources dedicated to specialised mental healthcare for patients with post-traumatic stress disorder (PTSD) within the US Veterans Health Administration, evidence-based psychotherapies (EBPs) for PTSD have been underutilised, as evidenced by low EBP reach to patients. A research-operation collaboration evaluated whether implementation facilitation delivered by regional PTSD mentors as part of a national mentoring programme improved EBP reach compared with less-intensive quality improvement interventions. We used a non-equivalent comparison-group design that included all PTSD clinics with low EBP reach at baseline (n=51). Clinics were grouped into one of four quality improvement conditions according to self-selection by regional PTSD mentors: facilitation (n=6), learning collaborative (n=15), mentoring as usual in the regions that had facilitation-target clinics (n=15) and mentoring as usual in other regions (n=15). The primary outcome was EBP reach among therapy patients with PTSD at preintervention baseline and postintervention sustainment periods. We used the ratio of odds ratios (ROR) between the two time periods to evaluate the effectiveness of facilitation compared with the other conditions, adjusting for patient-level and clinic-level confounders. 26 126 veterans with PTSD received psychotherapy in one of 51 low-reach PTSD clinics during preintervention baseline and postintervention sustainment periods. The odds of a patient receiving an EBP increased over time across conditions. The adjusted ORs of a patient receiving an EBP from baseline to sustainment were 1.35-1.69 times larger in clinics that received facilitation compared with the three comparison conditions (adjusted RORs of comparison condition versus facilitation ranged from 0.59 (95% CI 0.47 to 0.75) to 0.74 (95% CI 0.58 to 0.94)). Implementation facilitation can be integrated into a national programme for quality improvement for PTSD specialty care and may be particularly useful when less-intensive approaches are not sufficiently effective.
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Affiliation(s)
- Nina A Sayer
- CCDOR, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
- Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN, USA
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Kelly P Maieritsch
- Executive Division, National Center for PTSD, White River Junction VA Medical Center, White River Junction, Vermont, USA
| | - Cynthia A Yamokoski
- Executive Division, National Center for PTSD, White River Junction VA Medical Center, White River Junction, Vermont, USA
| | - Robert J Orazem
- CCDOR, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
| | | | - Siamak Noorbaloochi
- CCDOR, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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Preti B, Wang C, Dindial N, Malik S, Rieger S, Black M, Sachdeva R, Sanatani M. Assessment of urine colour using a wallet card: a randomised study of a novel patient self-care tool during chemoradiation for oesophageal cancer. BMJ Open Qual 2024; 13:e002439. [PMID: 38216293 PMCID: PMC10806581 DOI: 10.1136/bmjoq-2023-002439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 12/07/2023] [Indexed: 01/14/2024] Open
Abstract
BACKGROUND Patients undergoing neoadjuvant chemoradiation for oesophageal cancer often experience dehydration from decreased fluid intake and increased losses. Despite frequent clinical visits during treatment, patients can still present with dehydration, suggesting the need for increased patient awareness and engagement around adverse event management at home. Evidence for benefits of self-monitoring may help motivate patients to engage proactively in their own care to improve their treatment experience. METHODS We performed a randomised single-centre study of a urine colour self-monitoring card (UCC) during chemoradiation therapy for oesophageal cancer, compared with standard dietitian counselling. Primary outcome was self-efficacy as determined by the Self-Management Resource Centre Self-Efficacy for Managing Chronic Disease Scale (SMCD). Secondary outcomes included Burge thirst scores, Edmonton Symptom Assessment System scores (ESAS), patient-initiated hydrations, creatinine rise and satisfaction with the UCC. RESULTS Thirty-five patients were randomised. UCC use was not associated with improved SMCD or ESAS scores compared with standard counselling. The card was highly rated by patients as a welcome tool for self-monitoring. CONCLUSIONS No beneficial effect on self-efficacy or dehydration markers with UCC use was demonstrated. The study nonetheless drew attention to several factors potentially hindering its use for effective self-care: the unexpected severity of other symptoms consuming patients' attention, reduced sensitivity of urine colour due to chemotherapy, absence of active inquiry by the healthcare team and the inconvenient location of the UCC in wallet/purse. Urine colour monitoring in patients with oesophageal cancer to improve the patient experience during treatment warrants further study but supported by active healthcare provider inquiry, more accessible format of the card, and possibly home vital checks to increase its sensitivity in the clinical context.
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Affiliation(s)
- Beatrice Preti
- Department of Oncology, Western University, London, Ontario, Canada
| | - Cathy Wang
- Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | | | - Shiraz Malik
- Department of Family Medicine, Western University, London, Ontario, Canada
| | - Susan Rieger
- London Health Sciences Centre, London, Ontario, Canada
| | - Morgan Black
- London Regional Cancer Program, London Health Sciences Centre, London, Ontario, Canada
| | | | - Michael Sanatani
- Department of Oncology, Western University, London, Ontario, Canada
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Benevides Santos Paiva M, de Gouvêa Viana L, Melo de Andrade MV. Reduction of hospital length of stay through the implementation of SAFER patient flow bundle and Red2Green days tool: a pre-post study. BMJ Open Qual 2024; 13:e002399. [PMID: 38191217 PMCID: PMC10806560 DOI: 10.1136/bmjoq-2023-002399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 12/06/2023] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND In 2018, the National Health System released the 'Guide to reducing long hospital stays' to stimulate improvement and decrease length of stay (LOS) in England hospitals. The SAFER patient flow bundle and Red2Green tool were described as strategies to be implemented in inpatient wards to reduce discharge delays. OBJECTIVE To verify if implementing the SAFER patient flow bundle and Red2Green days tool is associated with LOS reduction in the internal medicine unit (IMU) wards of a university hospital in Brazil. METHODS In this pre post study, we compared the LOS of patients discharged from the IMU wards in 2019, during the implementation of the SAFER bundle and Red2Green tool, to the LOS of patients discharged in the same period in 2018. The Diagnosis-Related Group Brazil algorithm compared groups according to complexity and resource requirements. In-hospital mortality, readmission rates, the number of hospital acquired conditions and the number and causes of inappropriate hospital days were also evaluated. RESULTS Two hundred and eight internal medicine patients were discharged in 2018, and 252 were discharged in 2019. The median hospital LOS was significantly lower during the intervention period (14.2 days (IQR, 8-23) vs 19 days (IQR, 12-32); p<0.001). In-hospital mortality, 30-day mortality, readmission in 30 days and the number of hospital acquired conditions were the same between groups. Of the 3350 patient days analysed, 1482 (44.2%) were classified as green and 1868 (55.8%) as red. The lack of senior review was the most frequent cause of a red day (42.4%). CONCLUSION The SAFER patient flow bundle and Red2Green days tool implementation were associated with a significant decrease in hospital LOS in a university hospital IMU ward. There is a considerable improvement opportunity for hospital LOS reduction by changing the multidisciplinary team's attitude during patient hospitalisation using these strategies.
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Affiliation(s)
| | - Luciana de Gouvêa Viana
- Departamento de Propedeutica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Marcus Vinícius Melo de Andrade
- Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- Hospital Sirio-Libanes, Sao Paulo, Brazil
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Rowland E, Trueman H. Improving healthcare student experience of clinical placements. BMJ Open Qual 2024; 13:e002504. [PMID: 38176708 PMCID: PMC10773407 DOI: 10.1136/bmjoq-2023-002504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 12/02/2023] [Indexed: 01/06/2024] Open
Abstract
There is an expanding workforce gap in the NHS. Alongside national programmes to train, recruit and retain staff, efforts are needed on a local level. Clinical placements can make up to a third of healthcare student's time while at university thus placement experience is an important factor to reducing attrition rates at universities and increase conversion rates from student to qualified professional. This quality improvement project aimed to increase reported rates of students' satisfaction to 100% for each item of the student experience survey by March 2024 within Berkshire Healthcare National Health Service (NHS) Foundation Trust.To gain a deeper understanding of the experience and problems within healthcare student clinical placements interviews of students and staff were conducted alongside a literature review, which revealed six key themes around student placement experience: belonging and acceptance, familiarity and continuity, confidence and competence, preparation and preparedness, supervision and support, feeling overwhelmed/stress/impact on social and emotional health. These themes were translated into a student experience survey to achieve baseline and subsequent measurements.Changes were introduced to improve student satisfaction with clinical placements based on the baseline data of student satisfaction reported in the first student experience survey. Changes included introducing student inductions, better access to IT, student induction packs and newsletters. While the quantitative measurements of the items on the student experience survey remained positive, the nature of the qualitative feedback reflected the impact of the changes. Additionally, the improved communication and collaboration across teams because of the process highlighted the need for clear streamlined administrative processes. Regular review of student feedback has enabled timely feedback processes to placements and visible follow-up for students, highlighting the investment in them as the future workforce.
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Affiliation(s)
- Esther Rowland
- Berkshire Healthcare NHS Foundation Trust, Bracknell, UK
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Carsten BF, Bhandari P, Fortney BJ, Wilmes DS, Nelson CM, Brien AL, Walth RM, Anil G. Quality improvement initiative to improve communication domains of patient satisfaction in a regional community hospital with Six Sigma methodology. BMJ Open Qual 2023; 12:e002306. [PMID: 38160018 PMCID: PMC10759047 DOI: 10.1136/bmjoq-2023-002306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 12/17/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND Communication gaps, whether incomplete or fragmented communication, have been the cause of many disasters in human civilisation. Coordination of healthcare is directly related to proper communication and handoffs among multidisciplinary teams throughout multiple shifts during a patient's hospitalisation. LOCAL PROBLEM Patient surveys and direct patient feedback at Mayo Clinic Health System in Mankato, Minnesota, indicated that patient communication with physicians and nurses had declined in 2017 and 2018. Viewing this as an opportunity for improvement, our leadership initiated several changes to increase physician and nurse communication with patients, which resulted in no notable improvements. METHODS A systematic quality improvement approach was implemented by using Six Sigma methodology. Stakeholders from multidisciplinary teams were assembled as the project team. The five steps of Six Sigma methodology (Define, Measure, Analyse, Improve and Control) were followed to create a quality improvement intervention. INTERVENTION We developed a standardised and easy-to-use bedside team rounding tool to improve patient communication with physicians and nurses. RESULTS Postintervention patient satisfaction top-box scores exceeded target improvements for both physician (from 78.5% to 82.0%, p<0.01) and nurse (from 80.5% to 83.1%, p=0.04) communication domains. Physicians had a 33-point increase in percentile rank (from 41st to 74th percentile rank), and nurses had a 25-point increase in percentile rank (from 59th to 84th percentile rank). This increase in communication ranked our institution at the top of national benchmark organisations. CONCLUSIONS Overwhelmingly positive patient feedback was achieved, and postintervention employee satisfaction was primarily positive when compared with preintervention satisfaction.
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Affiliation(s)
- Brittan F Carsten
- Nursing, Mayo Clinic Health System - Southwest Minnesota Region, Mankato, Minnesota, USA
| | | | - Benjamin J Fortney
- Mayo Clinic Health System - Southwest Minnesota Region, Mankato, Minnesota, USA
| | - Danielle S Wilmes
- Nursing, Mayo Clinic Health System - Southwest Minnesota Region, Mankato, Minnesota, USA
| | - Cassandra M Nelson
- Nursing, Mayo Clinic Health System - Southwest Minnesota Region, Mankato, Minnesota, USA
| | - Amy L Brien
- Mayo Clinic Health System - Southwest Minnesota Region, Mankato, Minnesota, USA
| | - Rachel M Walth
- Nursing, Mayo Clinic Health System - Southwest Minnesota Region, Mankato, Minnesota, USA
| | - Gokhan Anil
- Mayo Clinic Health System - Southwest Minnesota Region, Mankato, Minnesota, USA
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List R, Solomon G, Bichl S, Horton BJ, Shen S, Corcoran B, Sadeghi H, Britto MT, Ren C, Albon D. Improved recognition of lung function decline as signal of cystic fibrosis pulmonary exacerbation: a Cystic Fibrosis Learning Network Innovation Laboratory quality improvement initiative. BMJ Open Qual 2023; 12:e002466. [PMID: 38154821 PMCID: PMC10759080 DOI: 10.1136/bmjoq-2023-002466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 12/12/2023] [Indexed: 12/30/2023] Open
Abstract
INTRODUCTION Cystic fibrosis (CF) is a systemic autosomal recessive condition characterised by progressive lung disease. CF pulmonary exacerbations (PEx) are episodes of worsening respiratory status, and frequent PEx are a risk factor for accelerated lung function decline, yet many people with CF (PwCF) go untreated at the time of decline. The goal of this quality improvement (QI) initiative was to improve recognition, treatment and follow-up of PEx in PwCF. METHODS Using the Model for Improvement, the Cystic Fibrosis Learning Network (CFLN) initiated a QI innovation laboratory (iLab) with a global aim to decrease the rate of lung function decline in PwCF. The iLab standardised definitions for signals of PEx using a threshold for decline in forced expiratory volume in one second (FEV1) and/or changes in symptoms. The FEV1 decline signal was termed FIES (FEV1-indicated exacerbation signal). Processes for screening and recognition of FIES and/or symptom changes, a treatment algorithm and follow-up in the presence of a signal were tested concurrently in multiple settings. SPECIFIC AIMS The specific aim is to increase the per cent of PwCF assessed for a PEx signal at ambulatory encounters and to increase the per cent of recommendations to follow-up within 6 weeks for PwCF experiencing a PEx signal. RESULTS FIES recognition increased from 18.6% to 73.4% across all teams during the iLab, and every team showed an improvement. Of PwCF assessed, 15.8% experienced an FIES event (>10% decline in FEV1 per cent predicted (FEV1pp)). Follow-up within 6 weeks was recommended for an average of 70.5% of those assessed for FIES and had an FEV1pp decline greater than 5%. CONCLUSION The CFLN iLab successfully defined and implemented a process to recognise and follow-up PEx signals. This process has the potential to be spread to the larger CF community. Further studies are needed to assess the impact of these processes on PwCF outcomes.
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Affiliation(s)
- Rhonda List
- Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - George Solomon
- Pulmonary, Allergy, & Critical Care Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Stacy Bichl
- Division of Pulmonary Medicine, Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | | | - Shiyi Shen
- Public Health Sciences, University of Virginia, Charlottesville, Virginia, USA
| | - Bean Corcoran
- Connecticut Chapter, Cystic Fibrosis Foundation, Weston, Connecticut, USA
| | - Hossein Sadeghi
- Pediatric Pulmonology and Sleep Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Maria T Britto
- Cincinnati Children's Hospital Medical Center James M Anderson Center for Health Systems Excellence, Cincinnati, Ohio, USA
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Clement Ren
- Division of Pulmonary and Sleep Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Dana Albon
- Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA
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Attanayake PM, Reither J. Development of a statistical analysis software for determining effectiveness of a comprehensive fall risk management protocol. BMJ Open Qual 2023; 12:e002450. [PMID: 38105241 PMCID: PMC10729082 DOI: 10.1136/bmjoq-2023-002450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 12/03/2023] [Indexed: 12/19/2023] Open
Abstract
INTRODUCTION As the leading cause of fatal injuries in geriatric populations, falls are a serious health concern with a predicted rate of seven fall-related deaths per hour by 2030. The Timed Up and Go (TUG) test is a screening tool proposed by the Center for Disease Control for evaluating patients' risk of falling ('fall risk'). However, there exist no current protocols on how to use the test results to decrease fall risk. The Fall Prevention Protocol (FPP) is a new comprehensive fall prevention programme created to address the lack of standardised TUG test follow-up in an Advanced Primary Care (APC) clinical setting. The programme provides a comprehensive approach for identifying fall risk and creating an individualised intervention plan to reduce the likelihood of falls. Due to the recent creation and implementation of FPP, there have been no efforts made to quantitatively prove that the FPP is more effective at reducing falls than the use of the TUG test alone without an established protocol for intervention. METHODS This quality improvement project focuses on creating a user-friendly statistical analysis software for determining the effectiveness of the FPP compared with just using the TUG test without a standardised post-test protocol in reducing the number of falls in geriatric patients in an APC setting. The software-created using MATLAB R2022b and finalised as a stand-alone computer application-takes in data sets of patient fall history, determines the best statistical test for comparing the data, then analyses and provides users with a conclusion regarding which protocol is more beneficial for reducing falls. RESULTS The developed software was proven to be user-friendly, able to be used in a healthcare setting with minimal necessary training, and deemed appropriate for data analysis of future fall risk protocol effectiveness testing.
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Affiliation(s)
| | - Jonathon Reither
- Internal Medicine, Corewell Health West Michigan, Holland, Michigan, USA
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Woodcock T, Matthew D, Palladino R, Nakubulwa M, Winn T, Bethell H, Hiles S, Moggan S, Dowell J, Sullivan P, Bell D, Cowie MR. Effect of implementing a heart failure admission care bundle on hospital readmission and mortality rates: interrupted time series study. BMJ Qual Saf 2023; 33:55-65. [PMID: 37931935 PMCID: PMC10804004 DOI: 10.1136/bmjqs-2022-015511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 08/15/2023] [Indexed: 11/08/2023]
Abstract
This study aimed to evaluate the impact of developing and implementing a care bundle intervention to improve care for patients with acute heart failure admitted to a large London hospital. The intervention comprised three elements, targeted within 24 hours of admission: N-terminal pro-B-type natriuretic peptide (NT-proBNP) test, transthoracic Doppler two-dimensional echocardiography and specialist review by cardiology team. The SHIFT-Evidence approach to quality improvement was used. During implementation, July 2015-July 2017, 1169 patients received the intervention. An interrupted time series design was used to evaluate impact on patient outcomes, including 15 618 admissions for 8951 patients. Mixed-effects multiple Poisson and log-linear regression models were fitted for count and continuous outcomes, respectively. Effect sizes are slope change ratios pre-intervention and post-intervention. The intervention was associated with reductions in emergency readmissions between 7 and 90 days (0.98, 95% CI 0.97 to 1.00), although not readmissions between 0 and 7 days post-discharge. Improvements were seen in in-hospital mortality (0.96, 95% CI 0.95 to 0.98), and there was no change in trend for hospital length of stay. Care process changes were also evaluated. Compliance with NT-proBNP testing was already high in 2014/2015 (162 of 163, 99.4%) and decreased slightly, with increased numbers audited, to 2016/2017 (1082 of 1101, 98.2%). Over this period, rates of echocardiography (84.7-98.9%) and specialist input (51.6-90.4%) improved. Care quality and outcomes can be improved for patients with acute heart failure using a care bundle approach. A systematic approach to quality improvement, and robust evaluation design, can be beneficial in supporting successful improvement and learning.
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Affiliation(s)
- Thomas Woodcock
- School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Dionne Matthew
- Strategy, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
- Life Science, LOGEX BV, Amsterdam, Netherlands
| | - Raffaele Palladino
- School of Public Health, Faculty of Medicine, Imperial College London, London, UK
- Department of Public Health, University of Naples Federico II School of Medicine and Surgery, Naples, Italy
| | - Mable Nakubulwa
- School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Trish Winn
- Research and Development, London Northwest University Healthcare NHS Trust, London, UK
| | - Hugh Bethell
- Cardiology, London Northwest University Healthcare NHS Trust, London, UK
| | - Stephen Hiles
- Research and Development, London Northwest University Healthcare NHS Trust, London, UK
| | - Susan Moggan
- Research and Development, London Northwest University Healthcare NHS Trust, London, UK
- Cardiology, London Northwest University Healthcare NHS Trust, London, UK
| | - Jackie Dowell
- Research and Development, London Northwest University Healthcare NHS Trust, London, UK
- Business Development, PHASTAR Specialist Biometric Contract Research Organisation, London, UK
| | - Paul Sullivan
- School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Derek Bell
- School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Martin R Cowie
- Royal Brompton Hospital & School of Cardiovascular Medicine, Faculty of Lifesciences & Medicine, King's College London, London, UK
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Powley N, Tew GA, Durrand J, Carr E, Nesbitt A, Hackett R, Gray J, McCarthy S, Beatty M, Huddleston R, Danjoux G. Digital health coaching to improve patient preparedness for elective lower limb arthroplasty: a quality improvement project. BMJ Open Qual 2023; 12:e002244. [PMID: 38061840 PMCID: PMC10711879 DOI: 10.1136/bmjoq-2022-002244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 11/03/2023] [Indexed: 12/18/2023] Open
Abstract
Major surgery carries high risks with comorbidities, frailty and health risk behaviours meaning patients are often unprepared for the physiological insult. Since 2018, the Prepwell programme at South Tees Hospitals NHS Foundation Trust has supported patients to improve their preoperative health and fitness. In April 2020, the face-to-face service was suspended due to the pandemic, leading to the team implementing a three-tiered remote digital support pathway, including digital health coaching via a mobile phone application. METHODS Patients scheduled for elective lower limb arthroplasty were offered 8 weeks of digital health coaching preoperatively. Following consent, participants were assigned a personal health coach to set individual behaviour change goals supported by online resources, alongside a digitally delivered exercise programme. Participants completed self-assessment questionnaires at Entry to, and Exit from, the programme, with outcome data collected 21 days postoperatively. The primary outcome was the change in Patient Activation Measure (PAM). RESULTS Fifty-seven of 189 patients (30.2%) consented to referral for digital health coaching. Forty participants completed the 8-week programme. Median PAM increased from 58.1 to 67.8 (p=0.002). Thirty-five per cent of participants were in a non-activated PAM level at Entry, reducing to 15% at Exit with no participants in PAM level 1 at completion. Seventy-one percent of non-activated participants improved their PAM by one level or more, compared with 45% for the whole cohort. Median LOS was 2 days, 1 day less than the Trust's arthroplasty patient population during the study period (unadjusted comparison). CONCLUSIONS Digital health coaching was successfully implemented for patients awaiting elective lower limb arthroplasty. We observed significant improvements in participants' PAM scores after the programme, with the largest increase in participants with lower activation scores at Entry. Further study is needed to confirm the effects of digital health coaching in this and other perioperative groups.
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Affiliation(s)
- Nicola Powley
- Northern School of Anaesthesia and Intensive Care Medicine, Newcastle upon Tyne, UK
| | | | - James Durrand
- Northern School of Anaesthesia and Intensive Care Medicine, Newcastle upon Tyne, UK
| | - Esther Carr
- South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | | | - Rhiannon Hackett
- Anaesthesia, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Joanne Gray
- Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Stephen McCarthy
- Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | | | | | - Gerard Danjoux
- Anaesthesia, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
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Roach P, Campbell P, Ody M, Scott M, Barnabe C, Montesanti S, Kennedy A, Murry A, Tailfeathers E, Crowshoe L. Access, Relationships, Quality and Safety (ARQS): a qualitative study to cocreate an Indigenous patient experience tool for virtual primary care. BMJ Open Qual 2023; 12:e002365. [PMID: 38061841 PMCID: PMC10711867 DOI: 10.1136/bmjoq-2023-002365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 11/15/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Perspectives from Indigenous peoples and their primary care providers about the quality and impacts of virtual primary care for Indigenous patients are currently limited. This study engaged Indigenous patients and their primary care providers, resulting in four domains being established for an Indigenous patient experience tool for use in virtual primary care. In this paper, we explore the development and finalisation of the Access, Relationships, Quality and Safety (ARQS) tool. METHODS We re-engaged five Indigenous patient participants who had been involved in the semistructured interviews that established the ARQS tool domains. Through cognitive interviews, we tested the tool statements, leading to modifications. To finalise the tool statements, an Indigenous advisory group was consulted. RESULTS The ARQS tool statements were revised and finalised with twelve statements that reflect the experiences and perspectives of Indigenous patients. DISCUSSION The ARQS tool statements assess the four domains that reflect high-quality virtual care for Indigenous patients. By centring Indigenous peoples and their lived experience with primary care at every stage in the tool's development, it captures Indigenous-centred understandings of high-quality virtual primary care and has validity for use in virtual primary care settings. CONCLUSION The ARQS tool offers a promising way for Indigenous patients to provide feedback and for clinics to measure the quality and safety of virtual primary care practice on the provider and/or clinic level. This is important, as such feedback may help to promote improvements in virtual primary care delivery for Indigenous patients and more widely, may help advance Indigenous health equity.
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Affiliation(s)
- Pamela Roach
- Family Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Paige Campbell
- Family Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Meagan Ody
- Family Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Melissa Scott
- Family Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Cheryl Barnabe
- Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | | | - Adam Murry
- Psychology, University of Calgary, Calgary, Alberta, Canada
| | | | - Lynden Crowshoe
- Family Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Kelly Y, O'Rourke N, Flynn R, O'Connor L, Hegarty J. Factors that influence the implementation of (inter)nationally endorsed health and social care standards: a systematic review and meta-summary. BMJ Qual Saf 2023; 32:750-762. [PMID: 37290917 PMCID: PMC10803983 DOI: 10.1136/bmjqs-2022-015287] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 04/15/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND Health and social care standards have been widely adopted as a quality improvement intervention. Standards are typically made up of evidence-based statements that describe safe, high-quality, person-centred care as an outcome or process of care delivery. They involve stakeholders at multiple levels and multiple activities across diverse services. As such, challenges exist with their implementation. Existing literature relating to standards has focused on accreditation and regulation programmes and there is limited evidence to inform implementation strategies specifically tailored to support the implementation of standards. This systematic review aimed to identify and describe the most frequently reported enablers and barriers to implementing (inter)nationally endorsed standards, in order to inform the selection of strategies that can optimise their implementation. METHODS Database searches were conducted in Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), SocINDEX, Google Scholar, OpenGrey and GreyNet International, complemented by manual searches of standard-setting bodies' websites and hand searching references of included studies. Primary qualitative, quantitative descriptive and mixed methods studies that reported enablers and barriers to implementing nationally or internationally endorsed standards were included. Two researchers independently screened search outcomes and conducted data extraction, methodological appraisal and CERQual (Confidence in Evidence from Reviews of Qualitative research) assessments. An inductive analysis was conducted using Sandelowski's meta-summary and measured frequency effect sizes (FES) for enablers and barriers. RESULTS 4072 papers were retrieved initially with 35 studies ultimately included. Twenty-two thematic statements describing enablers were created from 322 descriptive findings and grouped under six themes. Twenty-four thematic statements describing barriers were created from 376 descriptive findings and grouped under six themes. The most prevalent enablers with CERQual assessments graded as high included: available support tools at local level (FES 55%); training courses to increase awareness and knowledge of the standards (FES 52%) and knowledge sharing and interprofessional collaborations (FES 45%). The most prevalent barriers with CERQual assessments graded as high included: a lack of knowledge of what standards are (FES 63%), staffing constraints (FES 46%), insufficient funds (FES 43%). CONCLUSIONS The most frequently reported enablers related to available support tools, education and shared learning. The most frequently reported barriers related to a lack of knowledge of standards, staffing issues and insufficient funds. Incorporating these findings into the selection of implementation strategies will enhance the likelihood of effective implementation of standards and subsequently, improve safe, quality care for people using health and social care services.
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Affiliation(s)
- Yvonne Kelly
- Health Information and Standards Directorate, Health Information and Quality Authority (HIQA), Cork, Ireland
- Catherine McAuley School of Nursing and Midwifery and School of Public Health (SPHeRE programme), University College Cork, Cork, Ireland
| | - Niamh O'Rourke
- Health Information and Standards Directorate, Health Information and Quality Authority (HIQA), Dublin, Ireland
| | - Rachel Flynn
- Health Information and Standards Directorate, Health Information and Quality Authority (HIQA), Cork, Ireland
| | - Laura O'Connor
- Health Information and Standards Directorate, Health Information and Quality Authority (HIQA), Cork, Ireland
| | - Josephine Hegarty
- Catherine McAuley School of Nursing and Midwifery, University College Cork, Cork, Ireland
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van Linschoten RCA, Amini M, van Leeuwen N, Eijkenaar F, den Hartog SJ, Nederkoorn PJ, Hofmeijer J, Emmer BJ, Postma AA, van Zwam W, Roozenbeek B, Dippel D, Lingsma HF. Handling missing values in the analysis of between-hospital differences in ordinal and dichotomous outcomes: a simulation study. BMJ Qual Saf 2023; 32:742-749. [PMID: 37734955 DOI: 10.1136/bmjqs-2023-016387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 08/30/2023] [Indexed: 09/23/2023]
Abstract
Missing data are frequently encountered in registries that are used to compare performance across hospitals. The most appropriate method for handling missing data when analysing differences in outcomes between hospitals with a generalised linear mixed model is unclear. We aimed to compare methods for handling missing data when comparing hospitals on ordinal and dichotomous outcomes. We performed a simulation study using data from the Multicentre Randomised Controlled Trial of Endovascular Treatment for Acute Ischaemic Stroke in the Netherlands (MR CLEAN) Registry, a prospective cohort study in 17 hospitals performing endovascular therapy for ischaemic stroke in the Netherlands. The investigated methods for handling missing data, both case-mix adjustment variables and outcomes, were complete case analysis, single imputation, multiple imputation, single imputation with deletion of imputed outcomes and multiple imputation with deletion of imputed outcomes. Data were generated as missing completely at random (MCAR), missing at random and missing not at random (MNAR) in three scenarios: (1) 10% missing data in case-mix and outcome; (2) 40% missing data in case-mix and outcome; and (3) 40% missing data in case-mix and outcome with varying degree of missing data among hospitals. Bias and reliability of the methods were compared on the mean squared error (MSE, a summary measure combining bias and reliability) relative to the hospital effect estimates from the complete reference data set. For both the ordinal outcome (ie, the modified Rankin Scale) and a common dichotomised version thereof, all methods of handling missing data were biased, likely due to shrinkage of the random effects. The MSE of all methods was on average lowest under MCAR and with fewer missing data, and highest with more missing data and under MNAR. The 'multiple imputation, then deletion' method had the lowest MSE for both outcomes under all simulated patterns of missing data. Thus, when estimating hospital effects on ordinal and dichotomous outcomes in the presence of missing data, the least biased and most reliable method to handle these missing data is 'multiple imputation, then deletion'.
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Affiliation(s)
- Reinier C A van Linschoten
- Public Health, Erasmus MC, Rotterdam, Netherlands
- Gastroenterology and Hepatology, Franciscus Gasthuis en Vlietland, Rotterdam, Netherlands
- Department of Gastroenterology & Hepatology, Erasmus MC, Rotterdam, Netherlands
| | | | | | - Frank Eijkenaar
- Erasmus School of Health Policy and Management, Erasmus Universiteit Rotterdam, Rotterdam, Netherlands
| | - Sanne J den Hartog
- Public Health, Erasmus MC, Rotterdam, Netherlands
- Neurology, Erasmus MC, Rotterdam, Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus MC, Rotterdam, Netherlands
| | | | - Jeannette Hofmeijer
- Neurology, Rijnstate Hospital, Arnhem, Netherlands
- Clinical Neurophysiology, University of Twente, Enschede, Netherlands
| | - Bart J Emmer
- Radiology and Nuclear Medicine, Amsterdam UMC, Amsterdam, Netherlands
| | - Alida A Postma
- Radiology and Nuclear Medicine, MUMC+, Maastricht, Netherlands
- School for Mental Health and Sciences, Maastricht University, Maastricht, Netherlands
| | - Wim van Zwam
- Radiology and Nuclear Medicine, MUMC+, Maastricht, Netherlands
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Zhou MS, Jain T, Hardy N, Perez-Segura A, Hickman J, Leopold L, Qualliotine K, Yedidi RS, Whetsell M, Broffman L. The design, implementation, and impact of an automated patient-reported outcome data collection and adverse event surveillance tool: a randomized trial. BMC Health Serv Res 2023; 23:1277. [PMID: 37986191 PMCID: PMC10658802 DOI: 10.1186/s12913-023-10231-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 10/27/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND Incorporating patient-reported outcome measures into routine clinical care can improve the patient experience, increase engagement, and establish a structured method for gathering adverse event (AE) data. Systematically collecting this information on a large scale can also inform new solutions for removing treatment barriers like medication nonadherence. This study evaluated whether implementing a patient-reported outcome data collection and adverse event surveillance tool would result in greater treatment continuation for patients receiving care on a telehealth platform. METHODS We used iterative plan-study-do-act cycles to evaluate how this data collection and surveillance tool-a short prompt for patients to provide information on treatment satisfaction and side effects-impacted treatment continuation, the outcome of interest. We tested two cycles in n = 2,000 patients receiving care for erectile dysfunction on a telehealth platform as a randomized controlled trial, and accounted for incidents where true randomization was not possible during implementation. The first cycle tested the tool alone, while the second cycle tested the tool in conjunction with a messaging template system that provided standardized side effect counseling. RESULTS Compared to patients in the control group, patients in the intervention group were more likely to refill their prescription over the duration of the study period (75% vs. 71%, Kaplan Meier log-rank test, p = 0.04). Receiving standardized counseling as part of the AE response system was positively associated with treatment continuation (p = 0.0005). CONCLUSIONS Prompting patients to report side effects and outcomes outside of routine clinical visits has the potential to improve quality of care in virtual treatment. TRIAL REGISTRATION This trial has been retrospectively registered as a clinical trial (ClinicalTrials.gov Identifier: NCT05895539, registered June 8, 2023).
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Affiliation(s)
- Megan S Zhou
- Roman Health Ventures Inc, 116 W 23Rd St, New York, NY, 10011, USA
| | - Tanya Jain
- Roman Health Ventures Inc, 116 W 23Rd St, New York, NY, 10011, USA
| | - Nick Hardy
- Roman Health Ventures Inc, 116 W 23Rd St, New York, NY, 10011, USA
| | - Alejandro Perez-Segura
- Roman Health Ventures Inc, 116 W 23Rd St, New York, NY, 10011, USA
- Two Sigma, New York, NY, USA
| | - Jasmine Hickman
- Roman Health Ventures Inc, 116 W 23Rd St, New York, NY, 10011, USA
| | - Laurey Leopold
- Roman Health Ventures Inc, 116 W 23Rd St, New York, NY, 10011, USA
| | | | - Raagini S Yedidi
- Roman Health Ventures Inc, 116 W 23Rd St, New York, NY, 10011, USA
- Garden City Hospital, Garden City, MI, USA
| | - Matthew Whetsell
- Roman Health Ventures Inc, 116 W 23Rd St, New York, NY, 10011, USA
- Big Whale Labs, New York, NY, USA
| | - Lauren Broffman
- Roman Health Ventures Inc, 116 W 23Rd St, New York, NY, 10011, USA.
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Gillespie C, Wilhite JA, Hanley K, Hardowar K, Altshuler L, Fisher H, Porter B, Wallach A, Zabar S. Addressing social determinants of health in primary care: a quasi-experimental study using unannounced standardised patients to evaluate the impact of audit/feedback on physicians' rates of identifying and responding to social needs. BMJ Qual Saf 2023; 32:632-643. [PMID: 35623722 DOI: 10.1136/bmjqs-2021-013904] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 05/07/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Although efforts are underway to address social determinants of health (SDOH), little is known about physicians' SDOH practices despite evidence that failing to fully elicit and respond to social needs can compromise patient safety and undermine both the quality and effectiveness of treatment. In particular, interventions designed to enhance response to social needs have not been assessed using actual practice behaviour. In this study, we evaluate the degree to which providing primary care physicians with feedback on their SDOH practice behaviours is associated with increased rates of eliciting and responding to housing and social isolation needs. METHODS Unannounced standardised patients (USPs), actors trained to consistently portray clinical scenarios, were sent, incognito, to all five primary care teams in an urban, safety-net healthcare system. Scenarios involved common primary care conditions and each included an underlying housing (eg, mould in the apartment, crowding) and social isolation issue and USPs assessed whether the physician fully elicited these needs and if so, whether or not they addressed them. The intervention consisted of providing physicians with audit/feedback reports of their SDOH practices, along with brief written educational material. A prepost comparison group design was used to evaluate the intervention; four teams received the intervention and one team served as a 'proxy' comparison (no intervention). Preintervention (February 2017 to December 2017) rates of screening for and response to the scripted housing and social needs were compared with intervention period (January 2018 to March 2019) rates for both intervention and comparison teams. RESULTS 108 visits were completed preintervention and 183 during the intervention period. Overall, social needs were not elicited half of the time and fully addressed even less frequently. Rates of identifying the housing issue increased for teams that received audit/feedback reports (46%-60%; p=0.045) and declined for the proxy comparison (61%-42%; p=0.174). Rates of responding to housing needs increased significantly for intervention teams (15%-41%; p=0.004) but not for the comparison team (21%-29%; p=0.663). Social isolation was identified more frequently postintervention (53%) compared with baseline (39%; p=0.041) among the intervention teams but remained unchanged for the comparison team (39% vs 32%; p=0.601). Full exploration of social isolation remained low for both intervention and comparison teams. CONCLUSIONS Results suggest that physicians may not be consistently screening for or responding to social needs but that receiving feedback on those practices, along with brief targeted education, can improve rates of SDOH screening and response.
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Affiliation(s)
- Colleen Gillespie
- Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
- Institute for Innovations in Medical Education, NYU Grossman School of Medicine, New York, New York, USA
| | - Jeffrey A Wilhite
- Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Kathleen Hanley
- Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
- Ambulatory Care, New York City Health + Hospitals, New York, New York, USA
| | - Khemraj Hardowar
- Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Lisa Altshuler
- Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Harriet Fisher
- Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Barbara Porter
- Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Andrew Wallach
- Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
- Ambulatory Care, New York City Health + Hospitals, New York, New York, USA
| | - Sondra Zabar
- Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
- Ambulatory Care, New York City Health + Hospitals, New York, New York, USA
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Elsener M, Santana Felipes RC, Sege J, Harmon P, Jafri FN. Telehealth-based transitional care management programme to improve access to care. BMJ Open Qual 2023; 12:e002495. [PMID: 37940335 PMCID: PMC10632879 DOI: 10.1136/bmjoq-2023-002495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 10/26/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND The transition from hospital to home is a vulnerable time for patients and families that can be improved through care coordination and structured discharge planning. LOCAL PROBLEM Our organisation aimed to develop and expand a programme that could improve 30-day readmission rates on overall and disease-specific populations by assessing the impact of a telehealth outreach by a registered nurse (RN) after discharge from an acute care setting on 30-day hospital readmission. METHODS This is a prospective observational design conducted from May 2021 to December 2022 with an urban, non-academic, acute care hospital in Westchester County, New York. Outcomes for patients discharged home following inpatient hospitalisation were analysed within this study. We analysed overall and disease-specific populations (congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and pneumonia (PNA)) as compared with a 40-month prestudy cohort. INTERVENTIONS Patients were identified in a non-random fashion meeting criterion of being discharged home after an inpatient admission. Participants received a telephonic outreach by an RN within 72 hours of discharge. Contacted patients were asked questions addressing discharge instructions, medication access, follow-up appointments and social needs. Patients were offered services and resources based on their individual needs in response to the survey. RESULTS 68.2% of the 24 808 patients were contacted to assess and offer services. Median readmission rates for these patients were 1.2% less than the prestudy cohort (11.0% to 9.8%). Decreases were also noted for disease-specific conditions (CHF (14.3% to 9.1%), COPD (20.0% to 13.4%) and PNA (14.9% to 14.0%)). Among those in the study period, those that were contacted between 24 and 48 hours after discharge were 1.2 times less likely to be readmitted than if unable to be contacted (254/3742 (6.8%) vs 647/7866 (8.2%); p=0.005). CONCLUSIONS Using a multifaceted telehealth approach to improve patient engagement and access reduced 30-day hospital readmission for patients discharged from the acute care setting.
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Affiliation(s)
- Michelle Elsener
- Transitional Care, White Plains Hospital, White Plains, New York, USA
| | | | - Jonathan Sege
- Transitional Care, White Plains Hospital, White Plains, New York, USA
| | - Priscilla Harmon
- Transitional Care, White Plains Hospital, White Plains, New York, USA
| | - Farrukh N Jafri
- Emergency Department, White Plains Hospital, White Plains, New York, USA
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Moffat AK, Apajee J, Le Blanc VT, Westaway K, Andrade AQ, Ramsay EN, Blacker N, Pratt NL, Roughead EE. Reducing opioid use for chronic non-cancer pain in primary care using an evidence-based, theory-informed, multistrategic, multistakeholder approach: a single-arm time series with segmented regression. BMJ Qual Saf 2023; 32:623-631. [PMID: 37105724 PMCID: PMC10646855 DOI: 10.1136/bmjqs-2022-015716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 04/12/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND Many countries have high opioid use among people with chronic non-cancer pain. Knowledge about effective interventions that could be implemented at scale is limited. We designed a national intervention that included audit and feedback, deprescribing guidance, information on catastrophising assessment, pain neuroscience education and a cognitive tool for use by patients with their healthcare providers. METHOD We used a single-arm time series with segmented regression to assess rates of people using opioids before (January 2015 to September 2017), at the time of (October 2017) and after the intervention (November 2017 to August 2019). We used a cohort with historical comparison group and log binomial regression to examine the rate of psychologist claims in opioid users not using psychologist services prior to the intervention. RESULTS 13 968 patients using opioids, 8568 general practitioners, 8370 pharmacies and accredited pharmacists and 689 psychologists were targeted. The estimated difference in opioid use was -0.51 persons per 1000 persons per month (95% CI -0.69, -0.34; p<0.001) as a result of the intervention, equating to 25 387 (95% CI 24 676, 26 131) patient-months of opioid use avoided during the 22-month follow-up. The targeted group had a significantly higher rate of incident patient psychologist claims compared with the historical comparison group (rate ratio: 1.37, 95% CI 1.16, 1.63; p<0.001), equating to an additional 690 (95% CI 289, 1167) patient-months of psychologist treatment during the 22-month follow-up. CONCLUSIONS Our intervention addressed the cognitive, affective and sensory factors that contribute to pain and consequent opioid use, demonstrating it could be implemented at scale and was associated with a reduction in opioid use and increasing utilisation of psychologist services.
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Affiliation(s)
- Anna K Moffat
- Clinical and Health Sciences, University of South Australia, Adelaide, 5000, South Australia, Australia
| | - Jemisha Apajee
- Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Vanessa T Le Blanc
- Clinical and Health Sciences, University of South Australia, Adelaide, 5000, South Australia, Australia
| | - Kerrie Westaway
- Clinical and Health Sciences, University of South Australia, Adelaide, 5000, South Australia, Australia
| | - Andre Q Andrade
- Clinical and Health Sciences, University of South Australia, Adelaide, 5000, South Australia, Australia
| | - Emmae N Ramsay
- Clinical and Health Sciences, University of South Australia, Adelaide, 5000, South Australia, Australia
| | - Natalie Blacker
- Clinical and Health Sciences, University of South Australia, Adelaide, 5000, South Australia, Australia
| | - Nicole L Pratt
- Clinical and Health Sciences, University of South Australia, Adelaide, 5000, South Australia, Australia
| | - Elizabeth Ellen Roughead
- Clinical and Health Sciences, University of South Australia, Adelaide, 5000, South Australia, Australia
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