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Formative evaluation of the video reflexive ethnography method, as applied to the physician-nurse dyad

Quality and Safety in Health Care Journal -

Background

Despite decades of research and interventions, poor communication between physicians and nurses continues to be a primary contributor to adverse events in the hospital setting and a major challenge to improving patient safety. The lack of progress suggests that it is time to consider alternative approaches with greater potential to identify and improve communication than those used to date. We conducted a formative evaluation to assess the feasibility, acceptability and utility of using video reflexive ethnography (VRE) to examine, and potentially improve, communication between nurses and physicians.

Methods

We begin with a brief description of the institutional review boardapproval process and recruitment activities, then explain how we conducted the formative evaluation by describing (1) the VRE process itself; (2) our assessment of the exposure to the VRE process; and (3) challenges encountered and lessons learnt as a result of the process, along with suggestions for change.

Results

Our formative evaluation demonstrates that it is feasible and acceptable to video-record communication between physicians and nurses during patient care rounds across many units at a large, academic medical centre. The lessons that we learnt helped to identify procedural changes for future projects. We also discuss the broader application of this methodology as a possible strategy for improving other important quality and safety practices in healthcare settings.

Conclusions

The VRE process did generate increased reflection in both nurse and physician participants. Moreover, VRE has utility in assessing communication and, based on the comments of our participants, can serve as an intervention to possibly improve communication, with implications for patient safety.

External validity is also an ethical consideration in cluster-randomised trials of policy changes

Quality and Safety in Health Care Journal -

Hemming et al (‘Ethical Implications of Excessive Cluster Sizes in Cluster Randomized Trials’, 20 February 2018) cite the FIRST Trial as an example of a ‘higher risk’ cluster-randomised trial in which large cluster sizes pose unjustifiable excess risk.1 The authors state, ‘[t]he obvious way to reduce the cluster size in this study is to reduce the duration of the trial.’

We believe this to be an inappropriate recommendation stemming from an inaccurate appraisal of the FIRST Trial.

The FIRST Trial was designed to inform a potential policy change in US resident duty hours. In the Statistical Analysis Plan (SAP), which was made available at www.nejm.org, we clearly and prospectively stated, ‘[t]his study is a trial-based evaluation of potential policy effects on patient safety and resident wellbeing... this study is intended to inform real-world policy decision-making with respect to resident duty hours regulation.’2 The...

External validity is also an ethical consideration in cluster-randomised trials of policy changes: the authors reply

Quality and Safety in Health Care Journal -

We would like to thank the authors of the FIRST trial for responding to our paper on ‘Ethical implications of excessive cluster sizes in cluster randomised trials’.1 We are pleased that our paper has generated this interest. The science and methodology of trial design are constantly evolving and will evolve faster, to the future benefit of science, if we can openly reflect on how things have been done in the past and how we might do things differently in the future. We used the FIRST trial as a case study in our analysis as we believed it demonstrated potential for a more efficient design.

The FIRST authors make some valid points about pragmatic trials and large cluster sizes, that being that there are multiple factors to consider when designing trials. However, generalisability refers to the replication of the study results across different populations. Very large trials in...

Patient participation in inpatient ward rounds on acute inpatient medical wards: a descriptive study

Quality and Safety in Health Care Journal -

Background

Meaningful partnering with patients is advocated to enhance care delivery. Little is known about how this is operationalised at the point of care during hospital ward rounds, where decision-making concerning patient care frequently occurs.

Objective

Describe participation of patients, with differing preferences for participation, during ward rounds in acute medical inpatient services.

Methods

Naturalistic, multimethod design. Data were collected using surveys and observations of ward rounds at two hospitals in Melbourne, Australia. Using convenience sampling, a stratified sample of acute general medical patients were recruited. Prior to observation and interview, patient responses to the Control Preference Scale were used to stratify them into three groups representing diverse participation preferences: active control where the patient makes decisions; shared control where the patient prefers to make decisions jointly with clinicians; and passive control where the patient prefers clinicians make decisions.

Results

Of the 52 patients observed over 133 ward rounds, 30.8% (n=16) reported an active control preference for participation in decision-making during ward rounds, 25% (n=13) expressed shared control preference and 44.2% (n=23) expressed low control preference. Patients’ participation was observed in 75% (n=85) of ward rounds, but few rounds (18%, n=20) involved patient contribution to decisions about their care. Clinicians prompted patient participation in 54% of rounds; and in 15% patients initiated their own participation. Thematic analysis of qualitative observation and patient interview data revealed two themes, supporting patient capability and clinician-led opportunity, that contributed to patient participation or non-participation in ward rounds.

Conclusions

Participation in ward rounds was similar for patients irrespective of control preference. This study demonstrates the need to better understand clinician roles in supporting strategies that promote patient participation in day-to-day hospital care.

Virtual outpatient clinic as an alternative to an actual clinic visit after surgical discharge: a randomised controlled trial

Quality and Safety in Health Care Journal -

Background

It is standard practice to review all patients following discharge at a follow-up clinic but demands on all health services outweigh resources and unnecessary review appointments may delay or deny access to patients with greater needs.

Aims

This randomised trial aimed to establish whether a virtual outpatient clinic (VOPC) was an acceptable alternative to an actual outpatient clinic (OPC) attendance for a broad range of general surgical patients following a hospital admission.

Patients and methods

All patients admitted under one general surgical service over the study period were assessed. If eligible for inclusion the rationale, randomisation and follow-up methods were explained, consent was sought and patients randomised to receive either a VOPC or an OPC appointment.

Results

Two-hundred and nine patients consented to study inclusion, of which 98/107 (91.6%) in the VOPC group and 83/102 (81.4%) in the OPC group were successfully contacted. Only 6 patients in the OPC group and 10 in the VOPC group reported ongoing issues. A further follow-up indicated 78 of 82 (95%) VOPC patients were very happy with their overall experience compared with 34/61 (56%) in the actual OPC group (p<0.001). A significant proportion of both cohorts—68/82 (83%) in VOPC group and 41/61 (67%) in OPC group (p = 0.029)—preferred a VOPC appointment as their future follow-up of choice.

Conclusions

The majority of patients discharged from a surgical service could be better followed up by a virtual clinic with a significant proportion of patients reporting a preference for and a greater satisfaction with such a service.

Standardisation of perioperative urinary catheter use to reduce postsurgical urinary tract infection: an interrupted time series study

Quality and Safety in Health Care Journal -

Background

Prevention of healthcare-associated urinary tract infection (UTI) has been the focus of a national effort, yet appropriate indications for insertion and removal of urinary catheters (UC) among surgical patients remain poorly defined.

Methods

We developed and implemented a standardised approach to perioperative UC use to reduce postsurgical UTI including standard criteria for catheter insertion, training of staff to insert UC using sterile technique and standardised removal in the operating room and surgical unit using a nurse-initiated medical directive. We performed an interrupted time series analysis up to 2 years following intervention. The primary outcome was the proportion of patients who developed postsurgical UTI within 30 days as measured by the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). Process measures included monthly UC insertions, removals in the operating room and UC days per patient-days on surgical units.

Results

At baseline, 22.5% of patients were catheterised for surgery, none were removed in the operating room and catheter-days per patient-days were 17.4% on surgical units. Following implementation of intervention, monthly catheter removal in the operating room immediately increased (range 12.2%–30.0%) while monthly UC insertion decreased more slowly before being sustained below baseline for 12 months (range 8.4%–15.6%). Monthly catheter-days per patient-days decreased to 8.3% immediately following intervention with a sustained shift below the mean in the final 8 months. Postsurgical UTI decreased from 2.5% (95% CI 2.0-3.1%) to 1.4% (95% CI 1.1-1.9; p=0.002) during the intervention period.

Conclusions

Standardised perioperative UC practices resulted in measurable improvement in postsurgical UTI. These appropriateness criteria for perioperative UC use among a broad range of surgical services could inform best practices for hospitals participating in ACS NSQIP.

Speaking up about patient safety concerns: the influence of safety management approaches and climate on nurses willingness to speak up

Quality and Safety in Health Care Journal -

Background

Speaking up is important for patient safety, but healthcare professionals often hesitate to voice their concerns. Direct supervisors have an important role in influencing speaking up. However, good insight into the relationship between managers’ behaviour and employees’ perceptions about whether speaking up is safe and worthwhile is still lacking.

Aim

To explore the relationships between control-based and commitment-based safety management, climate for safety, psychological safety and nurses’ willingness to speak up.

Methods

We conducted a cross-sectional survey study, resulting in a sample of 980 nurses and 93 nurse managers working in Dutch clinical hospital wards. To test our hypotheses, hierarchical regression analyses (at ward level) and multilevel regression analyses were conducted.

Results

Significantly positive associations were found between nurses’ perceptions of control-based safety management and climate for safety (β=0.74; p<0.001), and between the perceived levels of commitment-based management and team psychological safety (β=0.36; p<0.01). Furthermore, team psychological safety is found to be positively related to nurses’ speaking up attitudes (B=0.24; t=2.04; p<0.05). The relationship between nurse-rated commitment-based safety management and nurses’ willingness to speak up is fully mediated by team psychological safety.

Conclusion

Results provide initial support that nurses who perceive higher levels of commitment-based safety management feel safer to take interpersonal risks and are more willing to speak up about patient safety concerns. Furthermore, nurses’ perceptions of control-based safety management are found to be positively related to a climate for safety, although no association was found with speaking up. Both control-based and commitment-based management approaches seem to be relevant for managing patient safety, but when it comes to encouraging speaking up, a commitment-based safety management approach seems to be most valuable.

Rate of avoidable deaths in a Norwegian hospital trust as judged by retrospective chart review

Quality and Safety in Health Care Journal -

Background

The proportion of avoidable hospital deaths is challenging to estimate, but has great implications for quality improvement and health policy. Many studies and monitoring tools are based on selected high-risk populations, which may overestimate the proportion. Mandatory reporting systems, however, under-report. We hypothesise that a review of an unselected sample of hospital deaths will provide an estimate of avoidability in-between the estimates from these methods.

Methods

A retrospective case record review of an unselected population of 1000 consecutive non-psychiatric hospital deaths in a Norwegian hospital trust was conducted. Reviewers evaluated to what degree each death could have been avoided, and identified problems in care.

Results

We found 42 (4.2%) of deaths to be at least probably avoidable (more than 50% chance of avoidability). Life expectancy was shortened by at least 1 year among 34 of the 42 patients with an avoidable death. Patients whose death was found to be avoidable were less functionally dependent compared with patients in the non-avoidable death group. The surgical department had the greatest proportion of such deaths. Very few of the avoidable deaths were reported to the hospital’s report system.

Conclusions

Avoidable hospital deaths occur less frequently than estimated by the national monitoring tool, but much more frequently than reported through mandatory reporting systems. Regular reviews of an unselected sample of hospital deaths are likely to provide a better estimate of the proportion of avoidable deaths than the current methods.

Michigan Appropriate Perioperative (MAP) criteria for urinary catheter use in common general and orthopaedic surgeries: results obtained using the RAND/UCLA Appropriateness Method

Quality and Safety in Health Care Journal -

Background

Indwelling urinary catheters are commonly used for patients undergoing general and orthopaedic surgery. Despite infectious and non-infectious harms of urinary catheters, there is limited guidance available to surgery teams regarding appropriate perioperative catheter use.

Objective

Using the RAND Corporation/University of California Los Angeles (RAND/UCLA) Appropriateness Method, we assessed the appropriateness of indwelling urinary catheter placement and different timings of catheter removal for routine general and orthopaedic surgery procedures.

Methods

Two multidisciplinary panels consisting of 13 and 11 members (physicians and nurses) for general and orthopaedic surgery, respectively, reviewed the available literature regarding the impact of different perioperative catheter use strategies. Using a standardised, multiround rating process, the panels independently rated clinical scenarios (91 general surgery, 36 orthopaedic surgery) for urinary catheter placement and postoperative duration of use as appropriate (ie, benefits outweigh risks), inappropriate or of uncertain appropriateness.

Results

Appropriateness of catheter use varied by procedure, accounting for procedure-specific risks as well as expected procedure time and intravenous fluids. Procedural appropriateness ratings for catheters were summarised for clinical use into three groups: (1) can perform surgery without catheter; (2) use intraoperatively only, ideally remove before leaving the operating room; and (3) use intraoperatively and keep catheter until postoperative days 1–4. Specific recommendations were provided by procedure, with postoperative day 1 being appropriate for catheter removal for first voiding trial for many procedures.

Conclusion

We defined the appropriateness of indwelling urinary catheter use during and after common general and orthopaedic surgical procedures. These ratings may help reduce catheter-associated complications for patients undergoing these procedures.

Addressing the challenges of knowledge co-production in quality improvement: learning from the implementation of the researcher-in-residence model

Quality and Safety in Health Care Journal -

The concept of knowledge co-production is used in health services research to describe partnerships (which can involve researchers, practitioners, managers, commissioners or service users) with the purpose of creating, sharing and negotiating different knowledge types used to make improvements in health services. Several knowledge co-production models have been proposed to date, some involving intermediary roles. This paper explores one such model, researchers-in-residence (also known as ‘embedded researchers’).

In this model, researchers work inside healthcare organisations, operating as staff members while also maintaining an affiliation with academic institutions. As part of the local team, researchers negotiate the meaning and use of research-based knowledge to co-produce knowledge, which is sensitive to the local context. Even though this model is spreading and appears to have potential for using co-produced knowledge to make changes in practice, a number of challenges with its use are emerging. These include challenges experienced by the researchers in embedding themselves within the practice environment, preserving a clear focus within their host organisations and maintaining academic professional identity.

In this paper, we provide an exploration of these challenges by examining three independent case studies implemented in the UK, each of which attempted to co-produce relevant research projects to improve the quality of care. We explore how these played out in practice and the strategies used by the researchers-in-residence to address them. In describing and analysing these strategies, we hope that participatory approaches to knowledge co-production can be used more effectively in the future.

Characteristics of healthcare organisations struggling to improve quality: results from a systematic review of qualitative studies

Quality and Safety in Health Care Journal -

Background

Identifying characteristics associated with struggling healthcare organisations may help inform improvement. Thus, we systematically reviewed the literature to: (1) Identify organisational factors associated with struggling healthcare organisations and (2) Summarise these factors into actionable domains.

Methods

Systematic review of qualitative studies that evaluated organisational characteristics of healthcare organisations that were struggling as defined by below-average patient outcomes (eg, mortality) or quality of care metrics (eg, Patient Safety Indicators). Searches were conducted in MEDLINE (via Ovid), EMBASE, Cochrane Library, CINAHL, and Web of Science from database inception through February 8 2018. Qualitative data were analysed using framework-based synthesis and summarised into key domains. Study quality was evaluated using the Critical Appraisal Skills Program tool.

Results

Thirty studies (33 articles) from multiple countries and settings (eg, acute care, outpatient) with a diverse range of interviewees (eg, nurses, leadership, staff) were included in the final analysis. Five domains characterised struggling healthcare organisations: poor organisational culture (limited ownership, not collaborative, hierarchical, with disconnected leadership), inadequate infrastructure (limited quality improvement, staffing, information technology or resources), lack of a cohesive mission (mission conflicts with other missions, is externally motivated, poorly defined or promotes mediocrity), system shocks (ie, events such as leadership turnover, new electronic health record system or organisational scandals that detract from daily operations), and dysfunctional external relations with other hospitals, stakeholders, or governing bodies.

Conclusions

Struggling healthcare organisations share characteristics that may affect their ability to provide optimal care. Understanding and identifying these characteristics may provide a first step to helping low performers address organisational challenges to improvement.

Systematic review registration

PROSPERO: CRD42017067367.

EHR-related alert fatigue: minimal progress to date, but much more can be done

Quality and Safety in Health Care Journal -

In BMJ Quality & Safety, Shah et al report their evaluation of the degree to which efforts in the US Veterans Health Administration to reduce electronic health record (EHR)-related information overload have achieved their goal.1 Studying the Veterans Health Information System and Technology Architecture (VistA), an internally developed EHR platform used throughout the Department of Veterans Affairs (VA) system, Shah and colleagues report that the median number of mandatory notification types at each VA facility decreased from 15 (IQR 13–19) to 10 (IQR 10–11) preintervention to postintervention, respectively (p<0.001). And, mean daily notifications per primary care physician decreased significantly from 128 to 116 (p<0.001).

I have several reactions to this contribution on EHR-related notifications to clinicians. The first is gratitude for devoting effort towards reducing physician burden and improving safety. A great deal has been written on shortcomings of EHRs and how dissatisfied physicians are with using...

Scaffolding our systems? Patients and families 'reaching in as a source of healthcare resilience.

Quality and Safety in Health Care Journal -

Redley and colleagues’ study1 suggests that involving patients in their care can be challenging, even when patients express a preference for involvement. Their paper examines a key opportunity for patient engagement—the ward round—and investigates the links between patients’ expressed preference to be involved and their observed level of involvement during subsequent ward rounds. The authors report little relationship between the two, concluding that involvement is affected by a range of contextual factors.

This finding, while disappointing, comes as little surprise to those who have spent any time in the ever-changing clinical environment of an acute hospital ward. What patients want in terms of active involvement, and what they can and do receive, varies in all kinds of ways. The reality of involving patients and families is that both preferences and opportunities for involvement are situated within a complex, dynamic healthcare system. Furthermore, it could be argued that...

Virtual postoperative clinic: can we push virtual postoperative care further upstream?

Quality and Safety in Health Care Journal -

Virtual care refers to remote healthcare interactions between patients and health professionals, predominantly using telecommunications networks. Virtual care interactions are a form of information exchange that guides care decisions. These interactions aim to enhance the patient experience and outcomes of care. Healthcare-related virtual care interactions can range from video clinic appointments to remote monitoring.1

The role of virtual care in surgery is rapidly evolving, and the nature of virtual interactions varies according to the phase of the surgical journey—spanning preoperative evaluation and assessment, preparation for surgery, intraoperative care and postoperative care.

The history of virtual surgical postoperative care actually goes back several decades. In a cohort of 536 patients with hip fracture published in 1990, telephone contact predicted return of function a year following surgery, likely due to improving patients’ psychological function, reinforcing postoperative medication regimens and encouraging consistent participation in rehabilitation.2

Despite a rapidly...

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