Sign in, time out, sign out checklist-changing practice through interdepartmental teamwork to improve safety at caesarean section

Three similar clinical incidences over a three-month period highlighted an issue with the readiness and availability of neonatal resuscitation personnel and equipment at the time of caesarean section (CS). This identified a potential risk to the wellbeing of the mother and baby that had to be addressed. A joint venture was undertaken with the maternity and theatre directorates. A maternity-specific checklist in use in the UK maternity services was sourced, adapted and implemented. No further incidents have been reported since with resulting overall enhanced safety of pregnant women and newborn babies in the unit.

Improving interdepartmental communication following a patient death

When patients die in emergency departments (EDs), it is important to record information that can be shared with staff in other departments, such as the mortuary and bereavement office. This can be a time-consuming exercise but, if information is omitted, it can increase families' distress by delaying documents such as death certificates. This article describes how a new, tick-box-style death-in-department checklist was introduced in a London hospital adult ED to increase and improve communication and information sharing between the ED, the mortuary and the bereavement office. Audits undertaken before and after the introduction of the checklist show a 75% increase in the recording and sharing of information between relevant departments. The positive effect of the new checklist has led to its introduction in another, associated ED, and it has been incorporated into the trust's end of life care policy.

Inter-role Relationships in Hospital-based Pharmacy and Therapeutics Committee Decision Making

The interdependencies of Pharmacy and Therapeutics Committee members in 222 teaching hospitals were studied by use of the social relations model. Cooperation, influence, frustration and enjoyment were studied among four-person subgroups chosen from the five roles recommended for hospitals by the American Society of Hospital Pharmacists: physician-chair, physician-nonchair, pharmacist, nurse and administrator. The results show that the elicitation and reception of cooperation, influence, frustration and enjoyment vary considerably by role (as manifest in actor and partner effects); small amounts of individual reciprocity (i.e. the association between actor and partner effects) were found for some measures of interdependence across roles, while small amounts of dyadic reciprocity (i.e. the association between reciprocal relationship effects) were found for many relationships. Significant group level (i.e. committee) effects were found as well.

Automatic Detection and Notification of “Wrong Patient—Wrong Location” Errors in the Operating Room

When procedures and processes to assure patient location based on human performance do not work as expected, patients are brought incrementally closer to a possible “wrong patient—wrong procedure” error. We developed a system for automated patient location monitoring and management. Realtime data from an active infrared/radio frequency identification tracking system provides patient location data that are robust and can be compared with an “expected process” model to automatically flag wrong-location events as soon as they occur. The system also generates messages that are automatically sent to process managers via the hospital paging system, thus creating an active alerting function to annunciate errors. We deployed the system to detect and annunciate “patientin-wrong-OR” events. The system detected all “ wrongoperating room (OR)” events, and all “wrong-OR” locations were correctly assigned within 0.50 ± 0.28 minutes (mean ± SD). This corresponded to the measured latency of the tracking system. All wrong-OR events were correctly annunciated via the paging function. This experiment demonstrates that current technology can automatically collect sufficient data to remotely monitor patient flow through a hospital, provide decision support based on predefined rules, and automatically notify stakeholders of errors.

Central Line Placement for the Pediatric Oncology Patient: A Model of Advanced Practice Nurse Collaboration

Central lines are commonly placed in pediatric oncology patients during their therapy. Advanced practice nurses (APNs) play an important role in the coordination and facilitation of line placements so that they may be inserted in an expeditious manner. Collaboration between the Divisions of Oncology and Surgery is often key to attaining this goal. At the Children’s Hospital of Philadelphia, the APNs in Oncology and Surgery have developed a collaborative approach to the placement of central lines in oncology patients. Many positive changes ensued between these divisions after collaboration occurred and a system for line placements was put into place. A well-defined process for central line placement is currently being utilized that meets the needs of the patients. Central lines are being placed in a timelier manner, procedures are coordinated, and treatment is started earlier, which has increased the satisfaction of patients, families, and health care providers. Finally, this collaboration led to an improved relationship and better communication between the Divisions of Oncology and Surgery.

Cultural implications of mentoring in sub-Saharan Africa: a qualitative study

CONTEXT

Although many studies have demonstrated the benefits of mentoring in academic medicine, conceptual understanding has been limited to studies performed in North America and Europe. An ecological model of mentoring in academic medicine can provide structure for a broader understanding of the role of culture in mentoring.

OBJECTIVE

The goal of this study was to explore the role of culture in the development and maintenance of mentoring relationships within the context of the University of Malawi College of Medicine.

METHODS

A qualitative study using in-depth, semi-structured interviews and thematic analysis was conducted to explore the meaning of mentorship at the study institution. Criterion sampling was used to identify and recruit medical students, interns, registrars and faculty members. Study team members developed a codebook through open coding and applied it to all interview transcripts. Thematic analysis was used to identify and categorise themes according to an ecological model.

RESULTS

A total of 46 participants from two major centres in Malawi were interviewed. Themes were identified within three domains: the intrapersonal; the interpersonal, and the institutional. Intrapersonal themes included Malawian politeness, mentoring needs, and friendliness and willingness to help. Interpersonal themes included understanding the role of the mentor, respect for elders, personal and professional boundaries, and perceptions of others. Institutional themes included the supervisor versus mentor, time pressures, tension about the scope of training, and the mentoring cycle.

CONCLUSIONS

This study highlights the strengths of and challenges imposed by culture to the provision of mentoring relationships at the study institution. It also highlights the central role of culture in mentoring and proposes an updated model for mentoring in academic medicine. This model can inform future research on mentoring and may serve as a model in the larger effort to provide faculty development in mentoring across sub-Saharan Africa.

Does formal mentoring for faculty members matter? A survey of clinical faculty members

BACKGROUND

Mentoring relationships, for all medical school faculty members, are an important component of lifelong development and education, yet an understanding of mentoring among medical school clinical faculty members is incomplete. This study examined associations between formal mentoring relationships and aspects of faculty members' engagement and satisfaction. It then explored the variability of these associations across subgroups of clinical faculty members to understand the status of mentoring and outcomes of mentoring relationships. The authors hypothesised that academic clinical faculty members currently in formal mentoring relationships experience enhanced employee engagement and satisfaction with their department and institution.

METHODS

Medical school faculty members at 26 self-selected USA institutions participated in the 2011-2014 Faculty Forward Engagement Survey. Responses from clinical faculty members were analysed for relationships between mentoring status and perceptions of engagement by faculty members.

RESULTS

Of the 11 953 clinical faculty respondents, almost one-third reported having a formal mentoring relationship (30%; 3529). Most mentored faculty indicated the relationship was important (86%; n = 3027), and over three-fourths were satisfied with their mentoring experience (77%; n = 2722). Mentored faculty members across ranks reported significantly higher levels of satisfaction and more positive perceptions of their roles in the organisation. Faculty members who were not receiving mentoring reported significantly less satisfaction with their workplace environment and lower overall satisfaction.

CONCLUSIONS

Mentored clinical faculty members have significantly greater satisfaction with their department and institution. This multi-institutional study provides evidence that fostering mentoring opportunities may facilitate faculty members' satisfaction and engagement, which, in turn, may help medical schools retain high-quality faculty staff committed to the multidimensional academic mission.

Developing and executing quality improvement projects (concept, methods, and evaluation)

Continuous quality improvement, quality assurance, cycles of change--these words of often used to express the process of using data to inform and improve clinical care. Although many of us have been exposed to theories and practice of experimental work (e.g., randomized trial), few of us have been similarly exposed to the science underlying quality improvement. Through the lens of a single-center quality improvement study, this article exposes the reader to methodology for conducting such studies. The reader will gain an understanding of these methods required to embark on such a study.

Teamwork, communication, formula-one racing and the outcomes of cardiac surgery

Most cardiac units achieve excellent results today, but the risk of cardiac surgery is still relatively high, and avoidable harm is common. The story of the Green Lane Cardiothoracic Unit provides an exemplar of excellence, but also illustrates the challenges associated with changes over time and with increases in the size of a unit and the complexity of practice today. The ultimate aim of cardiac surgery should be the best outcomes for (often very sick) patients rather than an undue focus on the prevention of error or adverse events. Measurement is fundamental to improving quality in health care, and the framework of structure, process, and outcome is helpful in considering how best to achieve this. A combination of outcomes (including some indicators of important morbidity) with key measures of process is advocated. There is substantial evidence that failures in teamwork and communication contribute to inefficiency and avoidable harm in cardiac surgery. Minor events are as important as major ones. Six approaches to improving teamwork (and hence outcomes) in cardiac surgery are suggested. These are: 1) subspecialize and replace tribes with teams; 2) sort out the leadership while flattening the gradients of authority; 3) introduce explicit training in effective communication; 4) use checklists, briefings, and debriefings and engage in the process; 5) promote a culture of respect alongside a commitment to excellence and a focus on patients; 6) focus on the performance of the team, not on individuals.

Protecting labor rights: roles for public health

Federal, state, and local labor laws establish minimum standards for working conditions, including wages, work hours, occupational safety, and collective bargaining. The adoption and enforcement of labor laws protect and promote social, economic, and physical determinants of health, while incomplete compliance undermines these laws and contributes to health inequalities. Using existing legal authorities, some public health agencies may be able to contribute to the adoption, monitoring, and enforcement of labor laws. We describe how routine public health functions have been adapted in San Francisco, California, to support compliance with minimum wage and workers' compensation insurance standards. Based on these experiences, we consider the opportunities and obstacles for health agencies to defend and advance labor standards. Increasing coordinated action between health and labor agencies may be a promising approach to reducing health inequities and efficiently enforcing labor standards.

Telepharmacology in clinical practice?

The role and collaboration of a pharmacologist with other members of the health care team is very important with his/her knowledge about prescribing, administration and pharmacodynamics of drugs as well as about using the existing drug related information systems. It seems optimal for a health care system to use telepharmacology which means a special pharmacological team (and information system) on duty available 24h to different medical specialists via remote multimedia link.

Perspective: a road map for academic departments to promote scholarship in quality improvement and patient safety

The fields of quality improvement and patient safety (QI/PS) continue to grow with greater attention and awareness, increased mandates and incentives, and more research. Academic medical centers and their academic departments have a long-standing tradition for innovation and scholarship within a multifaceted mission to provide patient care, educate the next generation, and conduct research. Academic departments are well positioned to lead the science, education, and application of QI/PS efforts nationally. However, meaningful engagement of faculty and trainees to lead this work is a major barrier. Understanding and developing programs that foster QI/PS work while also promoting a scholarly focus can generate the incentives and acknowledgment to help elevate QI/PS into the academic mission. Academic departments should define and articulate a QI/PS strategy, develop individual and departmental capacity to lead scholarly QI/PS programs, streamline and support access to data, share information and improve collaboration, and recognize and elevate academic success in QI/PS. A commitment to these goals can also serve to cultivate important collaborations between academic departments and their respective medical centers, divisions, and training programs. Ultimately, the elevation of QI/PS into the academic mission can improve the quality and safety of our health care delivery systems.

Does palliative care have a future in the emergency department? Discussions with attending emergency physicians

CONTEXT

Palliative care focuses on the relief of pain and suffering and achieving the best possible quality of life for patients. Although traditionally delivered in the inpatient setting, emergency departments (EDs) are a new focus for palliative care consultation teams.

OBJECTIVES

To explore attitudes and beliefs among emergency care providers regarding the provision of palliative care services in the ED.

METHODS

Three semistructured focus groups were conducted with attending emergency physicians from an academic medical center, a public hospital center, and a community hospital. The discussions were digitally recorded and transcribed to conduct a thematic analysis using grounded theory. A coding scheme was iteratively developed to subsequently identify themes and subthemes that emerged from the interviews.

RESULTS

Twenty emergency physicians participated (mean age 41 years, range 31-61 years, median practice time nine years, 40% female). Providers acknowledged many benefits of palliative care presence in the ED, including provision of a specialized skill set, time to discuss goals of care, and an opportunity to intervene for seriously ill or injured patients. Providers believed that concerns about medicolegal issues impaired their ability to forgo treatments where risks outweigh benefits. Additionally, the culture of emergency medicine-to provide stabilization of acute medical emergencies-was sometimes at odds with the culture of palliative care, which balances quality of life with the burdens of invasive treatments. Some providers also felt it was the primary physician's responsibility, and not their own, to address goals of care. Finally, some providers expressed concern that palliative care consultation was only available on weekdays during daytime hours. Automatic consultation based on predetermined criteria was suggested as a way to avoid conflicts with patients and family.

CONCLUSION

Emergency providers identified many benefits to palliative care consultation. Solving logistical problems and developing clear indications for consultation might help increase the use of such services.

Characteristics of dental clinics in US children's hospitals

PURPOSE

This study's purpose was to describe the workforce, patient, and service characteristics of dental clinics affiliated with US children's hospitals belonging to the National Association of Children's Hospital and Related Institutions (NACHRI).

METHODS

A 2-stage survey mechanism using ad hoc questionnaires sought responses from hospital administrators and dental clinic administrators. Questionnaires asked about: (1) clinic purpose; (2) workforce; (3) patient population; (4) dental services provided; (5) community professional relations; and (5) relationships with medical services.

RESULTS

Of the 222 NACHRI-affiliated hospitals, 87 reported comprehensive dental clinics (CDCs) and 64 (74%) of CDCs provided data. Provision of tertiary medical services was significantly related to presence of a CDC. Most CDCs were clustered east of the Mississippi River. Size, workload, and patient characteristics were variable across CDCs. Most were not profitable. Medical diagnosis was the primary criterion for eligibility, with all but 1 clinic treating special needs children. Most clinics (74%) had dental residencies. Over 75% reported providing dental care prior to major medical care (cardiac, oncology, transplantation), but follow-up care was variable.

CONCLUSIONS

Many children's hospitals reported comprehensive dental clinics, but the characteristics were highly variable, suggesting this element of the pediatric oral health care safety net may be fragile.

[The role of a mobile geriatrics team in surgical department]

The impact of ageing has favoured the emergence of new forms of work organisation, in particular the development of mobile geriatrics teams. Surgical departments have become the chosen area of interprofessional cooperation in line with the aim of providing quality care. Caregivers play a crucial role in detecting the need for and implementing geriatric treatment.

The informatics imperative in veterinary medicine: collaboration across disciplines

Information and data management are essential to support the collaborative and interdisciplinary pursuits of an academic veterinary medicine enterprise, ranging from research conducted by individual investigators, education processes, clinical care, and outreach to administration and management. Informatics is an academic discipline that focuses on the creation, management, storage, retrieval, and use of information and data and how technology can be applied to improve access to and use of these resources. In this article, we discuss the challenges in integrating informatics across a large academic enterprise from a veterinary medicine point of view. As a case study, we describe an example program of informatics at the University of Minnesota designed to support interdisciplinary collaboration.

Interdepartmental team earns leader quality award

Identifying issues as strategic initiatives can enhance likelihood of success. Interdepartmental quality improvement team includes director of case management and medical director of hospitalist program. Clinicians appreciated the fact that LOS was seen first and foremost as a medical issue.

Safety and 'silos' don't mix TJC says in new alert

Hold regular meetings involving representatives from all units and departments. Ensure adequate input from frontline staff; avoid a "top-down" approach. Within your department, hold joint meetings between physicians and nurses on an ongoing basis.

Post-acute service utilisation and parental satisfaction with health care services after mild traumatic brain injury in children and adolescents

The objectives of this study were to describe and analyse the current aftercare practise following define TBI in four German cities. A retrospective, cross-sectional design was chosen in order to investigate the research questions. Methods and procedures included a questionnaire mailed to parents whose children were admitted with TBI to one of seven collaborating hospitals. A total of 564 parents participated in the study. The results indicate that aftercare services were rarely utilised. Furthermore, it was found that the behaviour of the physician in charge had a great impact on parental satisfaction with healthcare services. In conclusion, the findings described in this article underline the need to improve communication between acute and post-acute services.

Multifaceted approach keeps patients flowing

If your ED's volume is steadily rising, chances are you won't be able to maintain smooth patient flow with a single strategy. The managers of the ED at Middle Tennessee Medical Center have maintained impressive door-to-doc times by pursuing a strategy of constantly implementing new processes to speed patient flow. These processes include: having the lab hire a phlebotomist specifically for the ED, to ensure the efficient transmission of lab tests orders and results; adding point-of-care testing for more common and time-consuming screenings such as creatinine and pregnancy urine tests; installing a system that enables the staff to receive wireless EKGs from the field.

Don't break the chain: importance of supply chain management in the operating room setting

Management of supplies within the operating room (OR) has considerable implications for decreasing healthcare costs while maintaining high-quality patient care. This area of healthcare therefore requires more monitoring by end-users including OR management, physicians, and nursing staff. This article is based on understanding supply chain management in the OR setting. Information provided throughout the article can be applied to small or large health care centers. It defines supply chain management and contains a brief overview of supply chain processes. It reviews the benefits of following these processes. The article also includes recommendations for improving the supply chain in the OR.

Streamlined process cuts time to triage in half

The two EDs in the Children's Healthcare of Atlanta have reduced their time to triage by 50% by eliminating assessment steps they considered nonessential. An ED leadership team, including assistant managers, administrative resource nurses, educators, trauma coordinators, managers, and physicians, reviewed the existing process. Steps eliminated included obtaining vital signs, conducting a full neurological assessment, using the stethoscope, or initiating procedures such as pain control or fever meds. The process was piloted with a select group of staff.

Implementing an electronic medical record

We consider the practical aspects of justifying, planning, implementing, and budgeting for an electronic medical record. Examples include the decision about integrating versus replacing old systems, the timing of implementation for each clinical area, preparation for installing computerized order entry, a discussion about how to implement physician progress notes, and a discussion about how electronic nursing systems interact with the EMR. Integration of other systems such as PACS and EKGs are discussed. Wireless integration and telemedicine also are addressed, as well as backup, redundant systems and budgeting. The reader will gain a full understanding of the scope of the problems involved in implementing an EMR, and will have a step-by-step description of how to approach the task.

Quality of neonatal care and outcome

High quality of care in neonatology implies providing an appropriate level of care to well newborn babies as well as more specialised care for the few babies who need it. Audit, surveillance and outcome studies may not always capture the complexity of quality of care and its contribution to outcome, and a more focused approach to standards of care evaluation may be required. Future progress in this field in the UK would benefit from a more coordinated approach from different organisations to bring together expertise in large database, management and analysis, audit and a national profile for feedback, evidence-based guidelines and guidelines development skills, expertise in the practice of changes together with the promotion by credible perinatal authorities of clinical practice.

Likelihood ratios reporting in a tertiary hospital emergency department; a pilot study

The Emergency Department and the laboratory of our institution jointly developed simple Clinical Pathways for some important clinical conditions (pulmonary embolism, acute myocardial infarction, bile-pancreatic disease) and since May 2004 the positive and negative likelihood ratios have been added to the reports of the tests included in the clinical pathways. In the first semester 30% of clinicians adopted the new mode of tests requesting AMI, Pulmonary embolism and bile pancreatic clinical pathways, respectively, 24% 32% and 42%. According to a survey carried out in 2004 all the ED staff had knowledge of the project. A real partnership developed between the laboratory staff and Emergency Department physicians leading to the adoption of the Evidence Based Laboratory Medicine tools in the decision making process.

The profit potential of hospital labs

Up to 90 percent of American hospitals have some type of laboratory outreach program, performing a test here or there for affiliated doctors in a nearby clinic. But a few hospitals have found that a more aggressive outreach program, with a relatively modest investment, can turn a cost center into a reliable profit center.