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Framework for direct observation of performance and safety in healthcare

Quality and Safety in Health Care Journal -

Introduction

Non-participant direct observation of healthcare processes offers a rich method for understanding safety and performance improvement. As a prospective method for error prediction and modelling, observation can capture a broad range of performance issues that can be related to higher aspects of the system.1–5 It can help identify underlying and recurrent problems6 that may be antecedents to more serious situations.7 It is also a way to understand the complexity of healthcare work that might otherwise be poorly understood or ignored,8 9 how workarounds influence work practices and safety,10 and is of fundamental importance to practitioners wishing to understand resilience in the face of conflicting workplace pressures.11 12 In some cases it will lead to the direct observation of near-misses or precursor events that...

Compassionate care: not easy, not free, not only nurses

Quality and Safety in Health Care Journal -

Compassion has historically been defined as an underpinning principle of work conducted by health professionals, especially nurses.1 Numerous definitions of compassionate care exist, incorporating a range of elements. Most include a cognitive element: understanding what is important to the other by exploring their perspective; a volitional element: choosing to act to try and alleviate the other’s disquiet; an affective element: actively imagining what the other is going through; an altruistic element: reacting to the other’s needs selflessly; and a moral element: to not show compassion may compound any pain or distress already being experienced by the other.2 3 Appeals for more compassionate care have become common within international discourses, through initiatives such as Schwartz Rounds established in America, Hearts in Healthcare in New Zealand, and the Asia Pacific Healthcare Hub of Charter for Compassion. In the UK, a policy document called Compassion in...

Remediation and rehabilitation programmes for health professionals: challenges for the future

Quality and Safety in Health Care Journal -

‘To improve is to change; to be perfect is to change often.’

—Winston Churchill

Health professions regulatory authorities are responsible for assessing the clinical performance of healthcare professionals.1 2 Some of them also have the responsibility for programming remediation interventions for health professionals with deficits in clinical performance.2 3 Available data on medical errors, malpractice claims, disciplinary actions and various other sources suggest that between 6% and 12% of physicians meet criteria for ‘dyscompetence’ in the USA.4 5 Elsewhere, the percentage varies according to the data sources.6 In Ontario, for instance, where the data come from randomly selected physicians, it is estimated that approximately 15% of family physicians and 3% of specialists have considerable deficiencies.4 7 8 Performance problems can have an impact on quality of care and...

Handoffs: whats good for residents is good for nurses...so whats next?

Quality and Safety in Health Care Journal -

Communicating patient information at shift change is a time-honoured nursing tradition. Historically referred to as ‘giving report’, the methods and information shared during nursing handoffs varied widely in modality (eg, face to face or through audio recordings), location (eg, in the break room, unit work centre or bedside) and format (eg, notes, formatted document or electronic health record). Although the shift change handoff process has evolved to increasingly emphasise face-to-face exchange and required data elements, variability persists,1 and the shift transition remains a vulnerable time for patients.

Shift changes generally, and the nursing handoff specifically, create gaps in care where errors may occur. In this issue of BMJ Quality and Safety, Starmer and colleagues2 describe a framework, IPASS, to bridge this gap. IPASS stands for Illness severity; Patient summary, Action list; Situation awareness and contingency planning; and Synthesis by receiver. IPASS is a handoff improvement bundle that provides a standardised structure...

Compassionate care: constitution, culture or coping?

Quality and Safety in Health Care Journal -

Alongside concern about avoidable mortality, one of the key findings of the public enquiry into failings at Mid Staffordshire NHS Foundation Trust,1 which ran Stafford Hospital in England, was the lack of compassion in care delivery. Sir Robert Francis, who led the enquiry, laid the blame for the compassion deficit at the door nursing and support staff. He recommended, among other things, that people should work as care assistants prior to nurse training and that values-based recruitment should be used to ensure that the ‘right’ people are recruited to be nurses. However, there has been little evidence to support these propositions. For example Snowden et al2 found that nursing students who had previous care jobs scored no higher for emotional intelligence than those without prior experience.

More recently opinion has shifted to the impact of compassionate leadership3 and compassionate environments on team behaviours....

Effects of the I-PASS Nursing Handoff Bundle on communication quality and workflow

Quality and Safety in Health Care Journal -

Background and objective

Handoff communication errors are a leading source of sentinel events. We sought to determine the impact of a handoff improvement programme for nurses.

Methods

We conducted a prospective pre-post intervention study on a paediatric intensive care unit in 2011–2012. The I-PASS Nursing Handoff Bundle intervention consisted of educational training, verbal handoff I-PASS mnemonic implementation, and visual materials to provide reinforcement and sustainability. We developed handoff direct observation and time motion workflow assessment tools to measure: (1) quality of the verbal handoff, including interruption frequency and presence of key handoff data elements; and (2) duration of handoff and other workflow activities.

Results

I-PASS implementation was associated with improvements in verbal handoff communications, including inclusion of illness severity assessment (37% preintervention vs 67% postintervention, p=0.001), patient summary (81% vs 95%, p=0.05), to do list (35% vs 100%, p<0.001) and an opportunity for the receiving nurse to ask questions (34% vs 73%, p<0.001). Overall, 13/21 (62%) of verbal handoff data elements were more likely to be present following implementation whereas no data elements were less likely present. Implementation was associated with a decrease in interruption frequency pre versus post intervention (67% vs 40% of handoffs with interruptions, p=0.005) without a change in the median handoff duration (18.8 min vs 19.9 min, p=0.48) or changes in time spent in direct or indirect patient care activities.

Conclusions

Implementation of the I-PASS Nursing Handoff Bundle was associated with widespread improvements in the verbal handoff process without a negative impact on nursing workflow. Implementation of I-PASS for nurses may therefore have the potential to significantly reduce medical errors and improve patient safety.

Patients and providers perceptions of the preventability of hospital readmission: a prospective, observational study in four European countries

Quality and Safety in Health Care Journal -

Objectives

Because of fundamental differences in healthcare systems, US readmission data cannot be extrapolated to the European setting: To investigate the opinions of readmitted patients, their carers, nurses and physicians on predictability and preventability of readmissions and using majority consensus to determine contributing factors that could potentially foresee (preventable) readmissions.

Design

Prospective observational study. Readmitted patients, their carers, and treating professionals were surveyed during readmission to assess the discharge process and the predictability and preventability of the readmission. Cohen’s Kappa measured pairwise agreement of considering readmission as predictable/preventable by patients, carers and professionals. Subsequently, multivariable logistic regressionidentified factors associated with predictability/preventability.

Setting

15 hospitals in four European countries

Participants

1398 medical patients readmitted unscheduled within 30 days

Main Outcome(s) and Measure(s)

(1) Agreement between the interviewed groups on considering readmissions likely predictable or preventable;(2) Factors distinguishing predictable from non-predictable and preventable from non-preventable readmissions.

Results

The majority deemed 27.8% readmissions potentially predictable and 14.4% potentially preventable. The consensus on predictability and preventability was poor, especially between patients and professionals (kappas ranged from 0.105 to 0.173). The interviewed selected different factors as potentially associated with predictability and preventability. When a patient reported that he was ready for discharge during index admission, the readmission was deemed less likely by the majority (predictability: OR 0.55; 95% CI 0.40 to 0.75; preventability: OR 0.35; 95% CI 0.24 to 0.49).

Conclusions

There is no consensus between readmitted patients, their carers and treating professionals about predictability and preventability of readmissions, nor associated risk factors. A readmitted patient reporting not feeling ready for discharge at index admission was strongly associated with preventability/predictability. Therefore, healthcare workers should question patients’ readiness to go home timely before discharge.

Optimising impact and sustainability: a qualitative process evaluation of a complex intervention targeted at compassionate care

Quality and Safety in Health Care Journal -

Background

Despite concerns about the degree of compassion in contemporary healthcare, there is a dearth of evidence for health service managers about how to promote compassionate healthcare. This paper reports on the implementation of the Creating Learning Environments for Compassionate Care (CLECC) intervention by four hospital ward nursing teams. CLECC is a workplace educational intervention focused on developing sustainable leadership and work-team practices designed to support team relational capacity and compassionate care delivery.

Objectives

To identify and explain the extent to which CLECC was implemented into existing work practices by nursing staff, and to inform conclusions about how such interventions can be optimised to support compassionate care in acute settings.

Methods

Process evaluation guided by normalisation process theory. Data gathered included staff interviews (n=47), observations (n=7 over 26 hours) and ward manager questionnaires on staffing (n=4).

Results

Frontline staff were keen to participate in CLECC, were able to implement many of the planned activities and valued the benefits to their well-being and to patient care. Nonetheless, factors outside of the direct influence of the ward teams mediated the impact and sustainability of the intervention. These factors included an organisational culture focused on tasks and targets that constrained opportunities for staff mutual support and learning.

Conclusions

Relational work in caregiving organisations depends on individual caregiver agency and on whether or not this work is adequately supported by resources, norms and relationships located in the wider system. High cognitive participation in compassionate nursing care interventions such as CLECC by senior nurse managers is likely to result in improved impact and sustainability.

How do hospital boards govern for quality improvement? A mixed methods study of 15 organisations in England

Quality and Safety in Health Care Journal -

Background

Health systems worldwide are increasingly holding boards of healthcare organisations accountable for the quality of care that they provide. Previous empirical research has found associations between certain board practices and higher quality patient care; however, little is known about how boards govern for quality improvement (QI).

Methods

We conducted fieldwork over a 30-month period in 15 healthcare provider organisations in England as part of a wider evaluation of a board-level organisational development intervention. Our data comprised board member interviews (n=65), board meeting observations (60 hours) and documents (30 sets of board meeting papers, 15 board minutes and 15 Quality Accounts). We analysed the data using a framework developed from existing evidence of links between board practices and quality of care. We mapped the variation in how boards enacted governance of QI and constructed a measure of QI governance maturity. We then compared organisations to identify the characteristics of those with mature QI governance.

Results

We found that boards with higher levels of maturity in relation to governing for QI had the following characteristics: explicitly prioritising QI; balancing short-term (external) priorities with long-term (internal) investment in QI; using data for QI, not just quality assurance; engaging staff and patients in QI; and encouraging a culture of continuous improvement. These characteristics appeared to be particularly enabled and facilitated by board-level clinical leaders.

Conclusions

This study contributes to a deeper understanding of how boards govern for QI. The identified characteristics of organisations with mature QI governance seemed to be enabled by active clinical leadership. Future research should explore the biographies, identities and work practices of board-level clinical leaders and their role in organisation-wide QI.

Controlled trial to improve resident sign-out in a medical intensive care unit

Quality and Safety in Health Care Journal -

Objective

Poor sign-out or handover of care may lead to preventable patient harm. Critically ill patients in intensive care units (ICU) are complex and prone to rapid clinical deterioration. If clinical deterioration occurs, timeliness of appropriate interventions is essential to prevent or reduce adverse outcomes. Therefore sign-outs need to efficiently transmit key information and provide anticipatory guidance. Interventions to improve resident-to-resident ICU sign-outs have not been well described. We conducted a controlled trial to test the effectiveness of a standardised ICU sign-out process to the usual ICU sign-out.

Design

Prospective controlled trial.

Setting

A 26-bed medical intensive care unit (MICU) in an urban tertiary academic medical centre.

Subjects

Residents rotating through the MICU.

Interventions

ICU-specific written sign-out template.

Methods

Residents completed postcall surveys assessing satisfaction with verbal and written sign-outs and incidence of non-routine events. Our main outcome of interest was the occurrence of non-routine events.

Main results

Compared with the intervention group, on significantly more nights, night float residents in the control group encountered patients who were sicker than sign-out would have suggested (15.94% vs 43.75%; p<0.0001). On significantly fewer nights, night float residents in the intervention group indicated that either something happened to patients that was unexpected (18.84% vs 36.51%; p=0.023) or they were insufficiently prepared for (4.35% vs 35.94%; p<0.0001). Similarly, on fewer nights, residents in the intervention group indicated that they had to perform interventions that were unplanned or unanticipated (15.9% vs 37.7%; p=0.005).

Conclusion

A structured sign-out process compared with usual sign-out significantly reduced the occurrence of non-routine events in an academic MICU.

A randomised controlled trial assessing the efficacy of an electronic discharge communication tool for preventing death or hospital readmission

Quality and Safety in Health Care Journal -

Objective

To assess the efficacy of an electronic discharge communication tool (e-DCT) for preventing death or hospital readmission, as well as reducing patient-reported adverse events after hospital discharge. The e-DCT assessed has already been shown to yield high-quality discharge summaries with high levels of patient and physician satisfaction.

Methods

This two-arm randomised controlled trial was conducted in a Canadian tertiary care centre’s internal medicine medical teaching units. Out of the 1953 patients approached and screened for inclusion, 1399 were randomised and available for data linkage for determination of the primary outcome. Participants were randomly assigned to e-DCT versus usual care (traditional discharge communication generated by dictation). The primary outcome was a composite of death or readmission within 90 days. The secondary outcome included any patient-reported adverse events within 30 days of discharge.

Results

Among 1399 randomised participants, 230 of 701 participants (32.8%) in the e-DCT group experienced the primary composite outcome of death or readmission within 90 days vs 205 of 698 participants (29.4%) in the usual care group (p=0.166). The incidence at 30 days of patient-reported adverse outcomes (35% for e-DCT vs 34% for usual care) and adverse events (2.1% for e-DCT vs 1.8% for usual care) also did not differ significantly between groups.

Conclusions

The e-DCT tested did not reduce the composite endpoint of death or readmission at 90 days, nor the incidence of patient-reported adverse events at 30 days. This neutral finding for hard clinical endpoints needs to be considered in the context of high patient and physician satisfaction, and high quality of discharge summaries.

Getting back on track: a systematic review of the outcomes of remediation and rehabilitation programmes for healthcare professionals with performance concerns

Quality and Safety in Health Care Journal -

Objective

To provide an overview of the evidence regarding outcomes of remediation and rehabilitation programmes for healthcare professionals with performance concerns, and to explore if outcomes differ for specific concerns and professions.

Methods

A search in four databases (Medline, Embase, PsycINFO and CINAHL) was conducted from 1 January 1990 to 7 May 2017. Studies reporting on outcomes of nationwide and state-wide programmes aimed at remediation and rehabilitating healthcare professionals with performance concerns (ie, dentists, midwives, nurses, pharmacists, physicians, physiotherapists, psychologists and psychotherapists) were included.

Results

We included a total of 38 studies. More than half of the studies included programmes in the USA (57.9%), and a majority of studies focused on outcomes for physicians (78.9%) and on outcomes for substance use disorders (SUDs, 63.2%). Programme completion rates for SUDs were positive and approximately 80%–90% of participants were employed after treatment. Studies that reported on remediation outcomes for dyscompetence, almost all from Canada (7/8), showed varying results. One study compared outcomes for performance concerns in the same programme (ie, SUD and other mental and behavioural problems) and showed comparably successful results. No study specifically compared outcomes between professions.

Conclusion

The literature is dominated by outcomes for physicians in North American programmes, with positive outcomes for SUD and varying outcomes for dyscompetence. Based on our findings we cannot make valid comparisons in outcomes between professions and specific performance concerns, and we call for other programmes to report on outcomes for different professions and concerns. Because of the positive outcomes of physician health programmes, other countries should consider introducing similar programmes to support healthcare professionals getting back on track.

Discharge to Assess: “Flipping” Discharge Assessment from Hospital to Home

Institute for Healthcare Improvement -

Discharge to Assess (D2A) (also referred to as "flipped discharge") is a redesign of the care process at Sheffield Teaching Hospitals in the UK that involves assessing a patient’s needs after discharge in the patient’s own home rather than in the hospital. Activities that traditionally happen at the end of a hospital admission are instead performed successfully and safely at home, thus enabling patients who are medically ready to go home earlier and spend less time in the acute care setting.

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