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Factors Influencing a Hospital-wide Intervention to Promote Professionalism and Build a Safety Culture

Institute for Healthcare Improvement -

A three-year qualitative study at an Australia hospital identifies valuable insights into factors influencing implementation of a multifaceted behavior change intervention to promote professionalism and build a culture of safety. The multiple interrelated factors impacting the hospital-wide intervention are discussed and analyzed.

The 7 Key Factors Driving $1 Trillion in Wasteful Health Care Spending

Institute for Healthcare Improvement -

The Institute for Healthcare Improvement recently released a call to action aimed at an audacious goal:identifying and eliminating 50 percent of all non-value-added waste in the health care system by 2025. This article dives into the report to understand how its authors measure and define waste, and to explore the drivers they identify.

What does it take to improve nationwide healthcare quality in China?

Quality and Safety in Health Care Journal -

Despite the great strides that have been made during China’s recent healthcare reform to improve access to healthcare,1 substantial gaps in quality persist.2 In a study of 33 tertiary hospitals in China, Jian and colleagues reported no improvement in most process indicators on healthcare quality for acute myocardial infarction, cerebral ischaemic stroke, chronic obstructive pulmonary disease and bacterial pneumonia, from 2013 to 2018.3This study provides the most contemporary evidence of quality trends during a 5-year period after the launch of China’s healthcare reform. More importantly, it covers a broad set of treatments for four common clinical conditions that are commonly used for assessing healthcare quality.4–9

The poor performance and lack of improvement in Chinese hospitals revealed in this study aligns with prior findings. In a nationally representative study on ST-segment elevation...

Challenges in translating mortality risk to the point of care

Quality and Safety in Health Care Journal -

Despite advances in medicine, prognostication remains inaccurate for many patients. Physicians tend to overestimate survival, even in advanced cancer and terminal illness groups.1–3 Over half of terminally ill patients express they do not want prolonging of life if their quality of life would decline.4 End-of-life interventions such as advanced care planning have shown improved adherence to patient’s wishes, improvement in satisfaction and reductions in stress, anxiety and depression,5 but clinicians remain reluctant to initiate end-of-life discussions with terminal patients if they are currently asymptomatic.6 Automated systems can complement clinician judgement to prompt earlier end-of-life discussions.

To this end, predictive analytics is potentially impactful. Many different approaches have been used to estimate mortality risk using factors including severity of illness,7 healthcare utilisation8 or comorbidities.9 However, few works focus on palliative or end-of-life...

Quality of care in large Chinese hospitals: an observational study

Quality and Safety in Health Care Journal -

Objective

To empirically assess the quality of hospital care in China and trends over a 5-year period during which the government significantly increased its investment in healthcare.

Design

Retrospective, observational study comparing hospital quality between two periods: October 2012–March 2013 and October 2017–March 2018.

Setting

1–2 of the most reputable large tertiary hospitals in each of the 25 provinces in Mainland China (total of 33).

Participants

Adults 18 years or older admitted with acute myocardial infarction (AMI) (n = 7031), cerebral ischaemic stroke (n = 12 008), chronic obstructive pulmonary disease (COPD) (n = 11 836) and bacterial pneumonia (n = 4263).

Main outcome measures

Process-based quality measures, including seven AMI measures, three stroke measures, four COPD measures and six pneumonia measures.

Results

In 2012/2013, Chinese hospitals had variable performance on AMI measures, including prescribing aspirin on arrival (80.7%), and discharging patients on aspirin (79.2%), β-blockers (60.8%) or statins (75.8%). This was similar for stroke cases and pneumonia cases. Smoking cessation advice was given at high rates across conditions though rates of influenza/pneumococcal vaccines were performed <1%. In 2017/2018, Chinese hospitals experienced no differences across most quality measures. Performance declined for two measures: aspirin on arrival for AMI cases and blood cultures before antibiotics for pneumonia cases. Performance increased for two measures: percutaneous coronary intervention within 90 min in ST segment elevation myocardial infarction cases (66.6% vs 80.1%, p<0.001) and statins at discharge for stroke cases (64.7% vs 78.7%, p<0.001). Compared with US hospitals, Chinese hospitals underperformed across most measures.

Conclusions

Chinese hospitals had low and variable performances across most quality measures for common medical conditions. Quality of care generally does not appear to be improving post national health reform. The Chinese government should include quality of care improvement in its health reform priorities to ensure patients receive appropriate and effective care.

mHOMR: a feasibility study of an automated system for identifying inpatients having an elevated risk of 1-year mortality

Quality and Safety in Health Care Journal -

Objective

The need for clinical staff to reliably identify patients with a shortened life expectancy is an obstacle to improving palliative and end-of-life care. We developed and evaluated the feasibility of an automated tool to identify patients with a high risk of death in the next year to prompt treating physicians to consider a palliative approach and reduce the identification burden faced by clinical staff.

Methods

Two-phase feasibility study conducted at two quaternary healthcare facilities in Toronto, Canada. We modified the Hospitalised-patient One-year Mortality Risk (HOMR) score, which identifies patients having an elevated 1-year mortality risk, to use only data available at the time of admission. An application prompted the admitting team when patients had an elevated mortality risk and suggested a palliative approach. The incidences of goals of care discussions and/or palliative care consultation were abstracted from medical records.

Results

Our model (C-statistic=0.89) was found to be similarly accurate to the original HOMR score and identified 15.8% and 12.2% of admitted patients at Sites 1 and 2, respectively. Of 400 patients included, the most common indications for admission included a frailty condition (219, 55%), chronic organ failure (91, 23%) and cancer (78, 20%). At Site 1 (integrated notification), patients with the notification were significantly more likely to have a discussion about goals of care and/or palliative care consultation (35% vs 20%, p = 0.016). At Site 2 (electronic mail), there was no significant difference (45% vs 53%, p = 0.322).

Conclusions

Our application is an accurate, feasible and timely identification tool for patients at elevated risk of death in the next year and may be effective for improving palliative and end-of-life care.

Disrupting activities in quality improvement initiatives: a qualitative case study of the QuICR Door-To-Needle initiative

Quality and Safety in Health Care Journal -

Background

Healthcare quality improvement (QI) efforts are ongoing but often create modest improvement. While knowledge about factors, tools and processes that encourage QI is growing, research has not attended to the need to disrupt established ways of working to facilitate QI efforts.

Objective

To examine how a QI initiative can disrupt professionals’ established way of working through a study of the Alberta Stroke Quality Improvement and Clinical Research (QuICR) Door-to-Needle Initiative.

Design

A multisite, qualitative case study, with data collected through semistructured interviews and focus groups. Inductive data analysis allowed findings to emerge from the data and supported the generation of new insights.

Findings

In stroke centres where improvements were realised, professionals’ established understanding of the clinical problem and their belief in the adequacy of existing treatment approaches shifted—they no longer believed that their established understanding and treating the clinical problem were appropriate. This shift occurred as participants engaged in specific activities to improve quality. We identify these activities as ones that create urgency, draw professionals away from regular work and encourage questioning about established processes. These activities constituted disrupting action in which both clinical and non-clinical persons were engaged.

Conclusions

Disrupting action is an important yet understudied element of QI. Disrupting action can be used to create gaps in established ways of working and may help encourage professionals’ involvement and support of QI efforts. While non-clinical professionals can be involved in disrupting action, it needs to engage clinical professionals on their own terms.

When order sets do not align with clinician workflow: assessing practice patterns in the electronic health record

Quality and Safety in Health Care Journal -

Background

Order sets are widely used tools in the electronic health record (EHR) for improving healthcare quality. However, there is limited insight into how well they facilitate clinician workflow. We assessed four indicators based on order set usage patterns in the EHR that reflect potential misalignment between order set design and clinician workflow needs.

Methods

We used data from the EHR on all orders of medication, laboratory, imaging and blood product items at an academic hospital and an itemset mining approach to extract orders that frequently co-occurred with order set use. We identified the following four indicators: infrequent ordering of order set items, rapid retraction of medication orders from order sets, additional a la carte ordering of items not included in order sets and a la carte ordering of items despite being listed in the order set.

Results

There was significant variability in workflow alignment across the 11 762 order set items used in the 77 421 inpatient encounters from 2014 to 2017. The median ordering rate was 4.1% (IQR 0.6%–18%) and median medication retraction rate was 4% (IQR 2%–10%). 143 (5%) medications were significantly less likely while 68 (3%) were significantly more likely to be retracted than if the same medication was ordered a la carte. 214 (39%) order sets were associated with least one additional item frequently ordered a la carte and 243 (45%) order sets contained at least one item that was instead more often ordered a la carte.

Conclusion

Order sets often do not align with what clinicians need at the point of care. Quantitative insights from EHRs may inform how order sets can be optimised to facilitate clinician workflow.

Mental well-being, job satisfaction and self-rated workability in general practitioners and hospitalisations for ambulatory care sensitive conditions among listed patients: a cohort study combining survey data on GPs and register data on patients

Quality and Safety in Health Care Journal -

Background

Physicians’ work conditions and mental well-being may affect healthcare quality and efficacy. Yet the effects on objective measures of healthcare performance remain understudied. This study examined mental well-being, job satisfaction and self-rated workability in general practitioners (GPs) in relation to hospitalisations for ambulatory care sensitive conditions (ACSC-Hs), a register-based quality indicator affected by referral threshold and prevention efforts in primary care.

Methods

This is an observational study combining data from national registers and a nationwide questionnaire survey among Danish GPs. To ensure precise linkage of each patient with a specific GP, partnership practices were not included. Study cases were 461 376 adult patients listed with 392 GPs. Associations between hospitalisations in the 6-month study period and selected well-being indicators were estimated at the individual patient level and adjusted for GP gender and seniority, list size, and patient factors (comorbidity, sociodemographic characteristics).

Results

The median number of ACSC-Hs per 1000 listed patients was 10.2 (interquartile interval: 7.0–13.7). All well-being indicators were inversely associated with ACSC-Hs, except for perceived stress (not associated). The adjusted incidence rate ratio was 1.26 (95% CI 1.13 to 1.42) for patients listed with GPs in the least favourable category of self-rated workability, and 1.19 (95% CI 1.05 to 1.35), 1.15 (95% CI 1.04 to 1.27) and 1.14 (95% CI 1.03 to 1.27) for patients listed with GPs in the least favourable categories of burn-out, job satisfaction and general well-being (the most favourable categories used as reference). Hospitalisations for conditions not classified as ambulatory care sensitive were not equally associated.

Conclusions

ACSC-H frequency increased with decreasing levels of GP mental well-being, job satisfaction and self-rated workability. These findings imply that GPs’ work conditions and mental well-being may have important implications for individual patients and for healthcare expenditures.

Impact of audit and feedback with action implementation toolbox on improving ICU pain management: cluster-randomised controlled trial

Quality and Safety in Health Care Journal -

Background

Audit and feedback (A&F) enjoys widespread use, but often achieves only marginal improvements in care. Providing recipients of A&F with suggested actions to overcome barriers (action implementation toolbox) may increase effectiveness.

Objective

To assess the impact of adding an action implementation toolbox to an electronic A&F intervention targeting quality of pain management in intensive care units (ICUs).

Trial design

Two-armed cluster-randomised controlled trial. Randomisation was computer generated, with allocation concealment by a researcher, unaffiliated with the study. Investigators were not blinded to the group assignment of an ICU.

Participants

Twenty-one Dutch ICUs and patients eligible for pain measurement.

Interventions

Feedback-only versus feedback with action implementation toolbox.

Outcome

Proportion of patient-shift observations where pain management was adequate; composed by two process (measuring pain at least once per patient in each shift; re-measuring unacceptable pain scores within 1 hour) and two outcome indicators (acceptable pain scores; unacceptable pain scores normalised within 1 hour).

Results

21 ICUs (feedback-only n=11; feedback-with-toolbox n=10) with a total of 253 530 patient-shift observations were analysed. We found absolute improvement on adequate pain management in the feedback-with-toolbox group (14.8%; 95% CI 14.0% to 15.5%) and the feedback-only group (4.8%; 95% CI 4.2% to 5.5%). Improvement was limited to the two process indicators. The feedback-with-toolbox group achieved larger effects than the feedback-only group both on the composite adequate pain management (p<0.05) and on measuring pain each shift (p<0.001). No important adverse effects have occurred.

Conclusion

Feedback with toolbox improved the number of shifts where patients received adequate pain management compared with feedback alone, but only in process and not outcome indicators.

Trial registration number

NCT02922101.

Sustaining effective quality improvement: building capacity for resilience in the practice facilitator workforce

Quality and Safety in Health Care Journal -

Background

Practice transformation efforts in healthcare, like the patient-centred medical home model in primary care, have spurred the development of multiple quality improvement (QI) and implementation strategies to support effective change. Nonetheless, uncertainty about how to implement and sustain change in complex healthcare settings1 2 continues to pose significant challenges. Even when practices are receptive,3 limited QI expertise, constrained resources,4 and associated staff morale and burnout5 can impact success. Although efforts among clinicians to improve primary care by embracing a culture of QI continue,6 healthcare systems are increasingly hiring additional personnel, like practice facilitators, with key performance improvement skills to promote and support change.7

However skilled, practice facilitators cannot implement change alone. Their primary function is to enable transformation by activating the healthcare context, the innovation being implemented and the actors implementing the innovation...

How do stakeholders experience the adoption of electronic prescribing systems in hospitals? A systematic review and thematic synthesis of qualitative studies

Quality and Safety in Health Care Journal -

Background

Electronic prescribing (ePrescribing) or computerised provider/physician order entry (CPOE) systems can improve the quality and safety of health services, but the translation of this into reduced harm for patients remains unclear. This review aimed to synthesise primary qualitative research relating to how stakeholders experience the adoption of ePrescribing/CPOE systems in hospitals, to help better understand why and how healthcare organisations have not yet realised the full potential of such systems and to inform future implementations and research.

Methods

We systematically searched 10 bibliographic databases and additional sources for citation searching and grey literature, with no restriction on date or publication language. Qualitative studies exploring the perspectives/experiences of stakeholders with the implementation, management, use and/or optimisation of ePrescribing/CPOE systems in hospitals were included. Quality assessment combined criteria from the Critical Appraisal Skills Programme Qualitative Checklist and the Standards for Reporting Qualitative Research guidelines. Data were synthesised thematically.

Results

79 articles were included. Stakeholders’ perspectives reflected a mixed set of positive and negative implications of engaging in ePrescribing/CPOE as part of their work. These were underpinned by further-reaching change processes. Impacts reported were largely practice related rather than at the organisational level. Factors affecting the implementation process and actions undertaken prior to implementation were perceived as important in understanding ePrescribing/CPOE adoption and impact.

Conclusions

Implementing organisations and teams should consider the breadth and depth of changes that ePrescribing/CPOE adoption can trigger rather than focus on discrete benefits/problems and favour implementation strategies that: consider the preimplementation context, are responsive to (and transparent about) organisational and stakeholder needs and agendas and which can be sustained effectively over time as implementations develop and gradually transition to routine use and system optimisation.

Identifying and quantifying variation between healthcare organisations and geographical regions: using mixed-effects models

Quality and Safety in Health Care Journal -

When the degree of variation between healthcare organisations or geographical regions is quantified, there is often a failure to account for the role of chance, which can lead to an overestimation of the true variation. Mixed-effects models account for the role of chance and estimate the true/underlying variation between organisations or regions. In this paper, we explore how a random intercept model can be applied to rate or proportion indicators and how to interpret the estimated variance parameter.

Reducing unnecessary sedative-hypnotic use among hospitalised older adults

Quality and Safety in Health Care Journal -

Background

Benzodiazepines and sedative hypnotics (BSH) have numerous adverse effects that can lead to negative outcomes, particularly in vulnerable hospitalised older adults. At our institution, over 15% of hospitalised older adults are prescribed sedative-hypnotics inappropriately. Of these prescriptions, 87% occurred at night to treat insomnia and almost 20% came from standard admission order sets.

Methods

We conducted a time-series study from January 2015 to August 2016 among medical and cardiology inpatients following the implementation in August 2015 of a sedative reduction bundle (education, removal of BSH from available admission order sets and non-pharmacological strategies to improve sleep). Preintervention period was January–July 2015 and postintervention period was August 2015–August 2016. A surgical ward served as control. Primary outcome was the proportion of BSH-naive (not on BSH prior to admission) patients 65 years or older discharged from medical and cardiology wards who were prescribed any new BSH for sleep in hospital. Data were analysed on statistical process control (SPC) p-charts with upper and lower limits set at 3 using standard rules. Secondary measures included Patient-reported Median Sleep Quality scores and rates of fall and sedating drug prescriptions that may be used for sleep (dimenhydrinate).

Results

During the study period, there were 5805 and 1115 discharges from the intervention and control units, respectively. From the mean baseline BSH prescription rate of 15.8%, the postintervention period saw an absolute reduction of 8.0% (95% CI 5.6% to 10.3%; p<0.001). Adjusted for temporal trends, the intervention produced a 5.3% absolute reduction in the proportion of patients newly prescribed BSH (95% CI 5.6% to 10.3%; p=0.002). BSH prescription rates remained stable on the control ward. Patient-reported measure of sleep quality, falls and use of other sedating medications remained unchanged throughout the study duration.

Conclusion

A comprehensive intervention bundle was associated with a reduction in inappropriate BSH prescriptions among older inpatients.

Precision Dose Inc. Issues Voluntary Nationwide Recall of Ranitidine Oral Solution, USP 150 mg/10 mL Due to Possible Presence of N-nitrosodimethylamine (NDMA) Impurity.

FDA MedWatch -

Precision Dose Inc. is voluntarily recalling 5 lots of Ranitidine Oral Solution, USP 150 mg/10 mL to the consumer level. Ranitidine Oral Solution, USP 150 mg/10 mL, is being recalled because of potential N-Nitrosodimethylamine (NDMA) amounts above levels established by the FDA.

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