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Pay-for-performance incentives for health worker vaccination: looking under the hood

Quality and Safety in Health Care Journal -

Since the earliest days of the COVID-19 vaccines, voluntary uptake of the vaccine by healthcare workers has been below optimal levels in many countries and across different healthcare systems.1–5 Health systems have implemented diverse initiatives to both increase healthcare worker motivation to vaccinate and close intention–behaviour gaps. Despite substantial effort to promote COVID-19 vaccination among healthcare workers in the USA, for example, nearly a third were not fully vaccinated as of September 2021.6 Many employers and governments have since considered or implemented vaccine mandates,7–9 with steep penalties for non-vaccination including termination.10 Notably, mandates for employees of hospitals, health systems and other healthcare entities receiving federal funds were recently upheld by the US Supreme Court.11

In this pressing policy context, scientists from several disciplines (behavioural science, improvement science,...

Replicating and publishing research in different countries and different settings: advice for authors

Quality and Safety in Health Care Journal -

At BMJ Quality & Safety, we frequently receive manuscripts that in some way replicate prior research. For example, authors submit research seeking to validate previously published tools such as safety climate surveys, to measure the frequency of a known safety event or quality concern or to test an existing intervention in new settings such as in different countries. This research is clearly important for stakeholders in the new setting concerned. However, a key question for us as editors is when such studies should be published in our journal, which has a broad and international remit, rather than a national or more context-specific journal.

We seek to publish research from a wide variety of settings, and indeed would like to publish high-quality work from a wider range of countries than we do at present. However, as for most international journals, we would not publish a study evaluating intervention ‘X’ or...

Speaking up in resource-constrained settings: how to secure safe surgical care in the moment and in the future?

Quality and Safety in Health Care Journal -

The provision of safe surgical care in low- and middle-income countries is challenging. Mortality and morbidity in the perioperative period are high and likely to rise as the burden of non-communicable diseases increases in these countries.1 Both access to, and quality of, surgical and perioperative care remain challenging in much of the world. In many African countries, for example, risk of mortality following surgery is around twice the global average, despite more favourable patient risk profiles in terms of age and acuity of condition.2 Resource deficiencies appear to be heavily implicated in these poorer outcomes, especially during postoperative care and for patients who would benefit from care and surveillance in intensive care facilities, which are scarce in low-income settings.3 However, as Mawuena and Mannion4 show in an article in this issue, resource limitations can have important impacts beyond their direct effect...

Improving health equity through clinical innovation

Quality and Safety in Health Care Journal -

Despite having the most expensive system of maternity care in the world, outcomes for birthing people in the USA are worse than other high-income nations. Critically, US outcomes also reflect deep and persistent racial and ethnic health disparities. The maternal mortality rate (deaths occurring within 42 days of pregnancy per 100 000 live births) in the USA was 23.8 in 2020, the highest of all comparable countries.1–5 Non-Hispanic black (NHB) and Native American individuals are two to three times more likely to die during or after childbirth compared with those who are non-Hispanic white (NHW).2 6 In contrast, maternal mortality outcomes for Hispanic and Asian/Pacific Islanders are generally comparable with those of NHW individuals,7 though some research findings suggest health disparities among specific subgroups.8 9 NHB and Native Americans also...

Unacceptable behaviours between healthcare workers: just the tip of the patient safety iceberg

Quality and Safety in Health Care Journal -

Since the publication of the 1999 ‘To Err is Human’ report by the Institute of Medicine, healthcare researchers have been attentive to factors potentially associated with iatrogenic risk, or in other words medical care that exacerbates or complicates an existing patient condition. While studies have explored a variety of patient factors (eg, age and weight of neonates1) and situational constraints (eg, staffing ratios and healthcare worker (HCW) sleep deprivation2 3), the risks posed by negative interpersonal interactions in healthcare contexts remain understudied and poorly understood. It is therefore timely that in BMJ Quality & Safety, Guo and colleagues4 present a systematic review of research examining the effects of unacceptable behaviours between HCWs on clinical performance and patient outcomes. Guo and colleagues’4 findings present an important step in raising awareness of the risks posed by negative interpersonal interactions among HCWs,...

Examining organisational responses to performance-based financial incentive systems: a case study using NHS staff influenza vaccination rates from 2012/2013 to 2019/2020

Quality and Safety in Health Care Journal -

Objective

Financial incentives are often applied to motivate desirable performance across organisations in healthcare systems. In the 2016/2017 financial year, the National Health Service (NHS) in England set a national performance-based incentive to increase uptake of the influenza vaccination among frontline staff. Since then, the threshold levels needed for hospital trusts to achieve the incentive (ie, the targets) have ranged from 70% to 80%. The present study examines the impact of this financial incentive across eight vaccination seasons.

Design

A retrospective observational study examining routinely recorded rates of influenza vaccination among staff in all acute NHS hospital trusts across eight vaccination seasons (2012/2013–2019/2020). The number of trusts included varied per year, from 127 to 137, due to organisational changes. McCrary’s density test is conducted to determine if the number of hospital trusts narrowly achieving the target by the end of each season is higher than would be expected in the absence of any responsiveness to the target. We refer to this bunching above the target threshold as a ‘threshold effect’.

Results

In the years before a national incentive was set, 9%–31% of NHS Trusts reported achieving the target, compared with 43%–74% in the 4 years after. Threshold effects did not emerge before the national incentive for payment was set; however, since then, threshold effects have appeared every year. Some trusts report narrowly achieving the target each year, both as the target rises and falls. Threshold effects were not apparent at targets for partial payments.

Conclusions

We provide compelling evidence that performance-based financial incentives produced threshold effects. Policymakers who set such incentives are encouraged to track threshold effects since they contain information on how organisations are responding to an incentive, what enquiries they may wish to make, how the incentive may be improved and what unintended effects it may be having.

Patterns, appropriateness and outcomes of peripherally inserted central catheter use in Brazil: a multicentre study of 12 725 catheters

Quality and Safety in Health Care Journal -

Background

Little is known about peripherally inserted central catheter (PICC) use, appropriateness and device outcomes in Brazil.

Methods

We conducted an observational, prospective, cohort study spanning 16 Brazilian hospitals from October 2018 to August 2020. Patients ≥18 years receiving a PICC were included. PICC placement variables were abstracted from medical records. PICC-related major (deep vein thrombosis (DVT), central line-associated bloodstream infection (CLABSI) and catheter occlusion) and minor complications were collected. Appropriateness was evaluated using the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC). Devices were considered inappropriate if they were in place for <5 days, were multi-lumen, and/or were placed in patients with a creatinine >2.0 mg/dL. PICCs considered appropriate met none of these criteria. Mixed-effects logistic regression models adjusting for patient-level and hospital-level characteristics assessed the association between appropriateness and major complications.

Results

Data from 12 725 PICCs were included. Mean patient age was 66.4±19 years and 51.0% were female. The most common indications for PICCs were intravenous antibiotics (81.1%) and difficult access (62.7%). Most PICCs (72.2%) were placed under ultrasound guidance. The prevalence of complications was low: CLABSI (0.9%); catheter-related DVT (1.0%) and reversible occlusion (2.5%). Of the 12 725 devices included, a total of 7935 (62.3%) PICCs were inappropriate according to MAGIC. With respect to individual metrics for appropriateness, 17.0% were placed for <5 days, 60.8% were multi-lumen and 11.3% were in patients with creatinine >2.0 mg/dL. After adjusting for patient and hospital-level characteristics, multi-lumen PICCs considered inappropriate were associated with greater odds of major complications (OR 2.54, 95% CI 1.61 to 4.02).

Conclusions

Use of PICCs in Brazilian hospitals appears to be safe and comparable with North America. However, opportunities to improve appropriateness remain. Future studies examining barriers and facilitators to improving device use in Brazil would be welcomed.

Implications of resource constraints and high workload on speaking up about threats to patient safety: a qualitative study of surgical teams in Ghana

Quality and Safety in Health Care Journal -

Background

Although under-resourcing of healthcare facilities and high workload is known to undermine patient safety, there is a dearth of evidence about how these factors affect employee voice and silence about unsafe care. We address this gap in the literature by exploring how resource constraints and high workload influence the willingness of staff to speak up about threats to patient safety in surgical departments in Ghana.

Method

Semistructured interviews with a purposeful sample of 91 multidisciplinary professionals drawn from a range of specialities, ranks and surgical teams in two teaching hospitals in Ghana. Conservation of Resources theory was used as a theoretical frame for the study. Data were processed and analysed thematically with the aid of NVivo 12.

Results

Endemic resource constraints and excessive workload generate stress that undermines employee willingness to speak up about unsafe care. The preoccupation with managing scarce resources predisposes managers in surgical units to ignore or downplay concerns raised and not to instigate appropriate remedial actions. Resource constraints lead to rationing and improvising in order to work around problems with inadequate infrastructure and malfunctioning equipment, which in turn creates unsupportive environments for staff to air legitimate concerns. Faced with high workloads, silence was used as a coping strategy by staff to preserve energy and avoid having to take on the burden of additional work.

Conclusion

Under-resourcing and high workload contribute significantly towards undermining employee voice about unsafe care. We highlight the central role that adequate funding and resourcing play in creating safe environments and that supporting ‘hearer’ courage may be as important as supporting speaking up in the first place.

Examining the effect of quality improvement initiatives on decreasing racial disparities in maternal morbidity

Quality and Safety in Health Care Journal -

The objective of this study was to evaluate the impact of quality improvement (QI) and patient safety initiatives and data disaggregation on racial disparities in severe maternal morbidity from hemorrhage (SMM-H).

Our hospital began monitoring and reporting on SMM-overall and SMM-H rates in 2018 using administrative data. In March 2019, we began stratifying data by race and ethnicity and noted a disparity in rates, with non-Hispanic Black women having the highest SMM rates. The data was presented as run charts at monthly department meetings. During this time, our hospital implemented several QI and patient safety initiatives around obstetric hemorrhage and used the stratified data to inform guideline development to reduce racial disparity. The initiatives included implementation of a hemorrhage patient safety bundle and in-depth case reviews of adverse patient outcomes with a health equity focus. We then retrospectively analyzed our data. Our outcome of interest was SMM-H prior to data stratification (pre-intervention: June 2018-February 2019) as compared to after data stratification (post-intervention: March 2019-June 2020).

During our study time period, there were 13,659 deliveries: 37% Hispanic, 35% White, 20% Black, 7% Asian and 1% Other. Pre-intervention, there was a statistically significant difference between Black and White women for SMM-H rates (p<0.001). This disparity was no longer significant post-intervention (p=0.138). The rate of SMM-H in Black women decreased from 45.5% to 31.6% (p=0.011).

Our findings suggest that QI and patient safety efforts that incorporate race and ethnicity data stratification to identify disparities and use the information to target interventions have the potential to reduce disparities in SMM.

Impact of unacceptable behaviour between healthcare workers on clinical performance and patient outcomes: a systematic review

Quality and Safety in Health Care Journal -

Background

Recent studies suggest that displays of unacceptable behaviour, including bullying, discrimination and harassment, between healthcare workers (HCWs) may impair job performance, and in turn, increase the frequency of medical errors, adverse events and healthcare-related complications. The objective of this systematic review was to summarise the current evidence of the impact of unacceptable behaviour occurring between HCWs on clinical performance and patient outcomes.

Methods

We searched MEDLINE, Embase, PsycINFO and CINAHL from 1 January 1990 to 31 March 2021. The search results were screened by two independent reviewers and studies were included if they were original research that assessed the effects of unacceptable behaviour on clinical performance, quality of care, workplace productivity or patient outcomes. Risk of bias was assessed using tools relevant to the study design and the data were synthesised without meta-analysis.

Results

From the 2559 screened studies, 36 studies were included: 22 survey-based studies, 4 qualitative studies, 3 mixed-methods studies, 4 simulation-based randomised controlled trials (RCTs) and 3 other study designs. Most survey-based studies were low quality and demonstrated that HCWs perceived a relationship between unacceptable behaviour and worse clinical performance and patient outcomes. This was supported by a smaller number of higher quality retrospective studies and RCTs. Two of four RCTs produced negative results, possibly reflecting inadequate power or study design limitations. No study demonstrated any beneficial effect of unacceptable behaviour on the study outcomes.

Conclusions

Despite the mixed quality of evidence and some inconsistencies in the strengths of associations reported, the overall weight of evidence shows that unacceptable behaviour negatively affects the clinical performance of HCWs, quality of care, workplace productivity and patient outcomes. Future research should focus on the evaluation and implementation of interventions that reduce the frequency of these behaviours.

Quality and Safety in the Literature: September 2022

Quality and Safety in Health Care Journal -

Healthcare quality and safety span multiple topics across the spectrum of academic and clinical disciplines. Keeping abreast of the rapidly growing body of work can be challenging. In this series, we provide succinct summaries of selected relevant studies published in the last several months. Some articles will focus on a particular theme, whereas others will highlight unique publications from high-impact medical journals.

Key points

  • Integration of a tablet computer-based delirium screening app into typical clinician workflow in two US hospitals was feasible, rapid and accurate and could be completed by certified nursing assistants, nurses and hospitalist physicians. Increased ease and clinician participation in delirium assessment may allow for greater delirium detection. Ann Intern Med. 9 November 2021.

  • A structured, daily, multicomponent delirium prevention intervention within German hospitals resulted in a significant reduction in rates of delirium and its duration in older patients undergoing...

  • Plastikon Healthcare Expands Voluntary Nationwide Recall of Milk of Magnesia Oral Suspension and Magnesium Hydroxide /Aluminum Hydroxide /Simethicone Oral Suspension Due to Microbial Contamination

    FDA MedWatch -

    Plastikon Healthcare, LLC is issuing an update to the voluntary recall initiated on June 3, 2022. The recall has been expanded to include Lot 20076A of Magnesium Hydroxide 1200 mg / Aluminum Hydroxide 1200 mg / Simethicone 120 mg per 30 mL Oral Suspension. This lot was previously subject to a retai

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