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Identifying patient and practice characteristics associated with patient-reported experiences of safety problems and harm: a cross-sectional study using a multilevel modelling approach

Quality and Safety in Health Care Journal -

Objective

To identify patient and family practice characteristics associated with patient-reported experiences of safety problems and harm.

Design

Cross-sectional study combining data from the individual postal administration of the validated Patient Reported Experiences and Outcomes of Safety in Primary Care (PREOS-PC) questionnaire to a random sample of patients in family practices (response rate=18.4%) and practice-level data for those practices obtained from NHS Digital. We built linear multilevel multivariate regression models to model the association between patient-level (clinical and sociodemographic) and practice-level (size and case-mix, human resources, indicators of quality and safety of care, and practice safety activation) characteristics, and outcome measures.

Setting

Practices distributed across five regions in the North, Centre and South of England.

Participants

1190 patients registered in 45 practices purposefully sampled (maximal variation in practice size and levels of deprivation).

Main outcome measures

Self-reported safety problems, harm and overall perception of safety.

Results

Higher self-reported levels of safety problems were associated with younger age of patients (beta coefficient 0.15) and lower levels of practice safety activation (0.44). Higher self-reported levels of harm were associated with younger age (0.13) and worse self-reported health status (0.23). Lower self-reported healthcare safety was associated with lower levels of practice safety activation (0.40). The fully adjusted models explained 4.5% of the variance in experiences of safety problems, 8.6% of the variance in harm and 4.4% of the variance in perceptions of patient safety.

Conclusions

Practices’ safety activation levels and patients’ age and health status are associated with patient-reported safety outcomes in English family practices. The development of interventions aimed at improving patient safety outcomes would benefit from focusing on the identified groups.

Reliable adherence to a COPD care bundle mitigates system-level failures and reduces COPD readmissions: a system redesign using improvement science

Quality and Safety in Health Care Journal -

Background

Readmissions of chronic obstructive pulmonary disease (COPD) have devastating effects on patient quality-of-life, disease progression and healthcare cost. Effective interventions to reduce COPD readmissions are needed.

Objectives

Reduce 30-day all-cause readmissions by (1) creating a COPD care bundle that addresses care delivery failures, (2) using improvement science to achieve 90% bundle adherence.

Setting

An 800-bed academic hospital in Ohio, USA. The COPD 30-day all-cause readmission rate was 22.7% from August 2013 to September 2015.

Method

We performed a cross-sectional study of COPD 30-day readmissions from October 2014 to March 2015 to identify care delivery failures. We interviewed readmitted patients with COPD to identify their needs after discharge. A multidisciplinary team created a care bundle designed to mitigate system failures. Using a quasi-experimental study and ‘Model for Improvement’, we redesigned care delivery to improve bundle adherence. We used statistical process control charts to analyse bundle adherence and all-cause 30-day readmissions.

Results

Cross-sectional review of the index (first-time) admissions revealed COPD was the most common readmission diagnosis and identified 42 system-level failures. The most prevalent failures were deficient inhaler regimen at discharge, late or non-existent follow-up appointments, and suboptimal discharge instructions. Patient interviews revealed confusing discharge instructions, especially regarding inhaler use. The COPD care-bundle components were: (1) appropriate inhaler regimen, (2) 30-day inhaler supply, (3) inhaler education on the device available postdischarge, (4) follow-up within 15 days (5) standardised patient-centred discharge instructions. The adherence to completing bundle components reached 90% in 5.5 months and was sustained. The COPD 30-day readmission rate decreased from 22.7% to 14.7%. Patients receiving all bundle components had a readmission rate of 10.9%. As a balancing measure for the targeted reduction in readmission rate, we assessed length of stay, which did not change (4.8 days before vs 4.6 days after; p=0.45).

Conclusion

System-level failures and unmet patient needs are modifiable risks for readmissions. Development and reliable implementation of a COPD care bundle that mitigates these failures reduced COPD readmissions.

Comparison of control charts for monitoring clinical performance using binary data

Quality and Safety in Health Care Journal -

Background

Time series charts are increasingly used by clinical teams to monitor their performance, but statistical control charts are not widely used, partly due to uncertainty about which chart to use. Although there is a large literature on methods, there are few systematic comparisons of charts for detecting changes in rates of binary clinical performance data.

Methods

We compared four control charts for binary data: the Shewhart p-chart; the exponentially weighted moving average (EWMA) chart; the cumulative sum (CUSUM) chart; and the g-chart. Charts were set up to have the same long-term false signal rate. Chart performance was then judged according to the expected number of patients treated until a change in rate was detected.

Results

For large absolute increases in rates (>10%), the Shewhart p-chart and EWMA both had good performance, although not quite as good as the CUSUM. For small absolute increases (<10%), the CUSUM detected changes more rapidly. The g-chart is designed to efficiently detect decreases in low event rates, but it again had less good performance than the CUSUM.

Implications

The Shewhart p-chart is the simplest chart to implement and interpret, and performs well for detecting large changes, which may be useful for monitoring processes of care. The g-chart is a useful complement for determining the success of initiatives to reduce low-event rates (eg, adverse events). The CUSUM may be particularly useful for faster detection of problems with patient safety leading to increases in adverse event rates.  

Incorporating nursing complexity in reimbursement coding systems: the potential impact on missed care

Quality and Safety in Health Care Journal -

Introduction 

Globally, nurses constitute the largest segment of healthcare professionals; therefore, they are also the most expensive, and in a hospital these costs can reach 25% of the total expenditure.1 When costs are calculated, usually the monthly sum of nursing working hours and nursing labour costs is divided by the total number of patient days to produce mean general measures such as ‘nursing hours per patient’ or ‘nursing costs per patient day.’ This is only a general average cost calculation that takes into account large groups of nurses caring for large groups of patients, but through this system it is difficult to accurately control costs if the specific costs are unknown.2 In this regard, Needleman3 pointed to the ‘invisibility’ of a significant portion of nursing today, which explains why this discipline in many countries around the world is still not fully recognised by...

How to attribute causality in quality improvement: lessons from epidemiology

Quality and Safety in Health Care Journal -

Background

Quality improvement and implementation (QI&I) initiatives face critical challenges in an era of evidence-based, value-driven patient care. Whether front-line staff, large organisations or government bodies design and run QI&I, there is increasing need to demonstrate impact to justify investment of time and resources in implementing and scaling up an intervention.

Decisions about sustaining, scaling up and spreading an initiative can be informed by evidence of causation and the estimated attributable effect of an intervention on observed outcomes. Achieving this in healthcare can be challenging, where interventions often are multimodal and applied in complex systems.1 Where there is weak evidence of causation, credibility in the effectiveness of the intervention is reduced with a resultant reduced desire to replicate. The greater confidence of a causal relationship between QI&I interventions and observed results, the greater our confidence that improvement will result when the intervention occurs in different settings.

...

Standard admission order sets promote ordering of unnecessary investigations: a quasi-randomised evaluation in a simulated setting

Quality and Safety in Health Care Journal -

Introduction

Standard admission order sets have become ubiquitous across hospitals to promote adherence to practice guidelines and increase ordering efficiency.1 2 This standardisation arose in part out of a need to minimise waste in healthcare, a phenomenon identified as a major barrier to reducing future healthcare costs.3 However, few studies have systematically evaluated whether these standardised orders can actually promote overordering of investigations. At our academic hospital’s coronary care unit (CCU), a single mandatory generic order set is used regardless of admitting diagnosis and includes optional check boxes for serum thyroid-stimulating hormone (TSH) and brain natriuretic peptide (BNP). We postulated that physicians order investigations differently on admission based on which investigations are included in the admission order set.

Methods

We quasi-randomised a convenience sample of participants in a double-blind fashion to receive either our standard CCU admission order set or...

Speaking up against unsafe unprofessional behaviours: the difficulty in knowing when and how

Quality and Safety in Health Care Journal -

Patient safety is a core focus now in medical education, with an increasing number of training programmes educating learners about its key tenets.1–3 Residents now undergo formal training about the importance of contributing to a culture of safety by speaking up to avoid errors or harm, but still face difficulties enacting these behaviours in practice.4 In this issue of the journal, Martinez et al have attempted to tease out differences in speaking-out behaviours between traditional and professionalism-related patient safety threats.5 The authors have raised several interesting points worthy of further exploration. In this editorial we focus on unprofessional behaviour as a potential threat to patient safety and propose some new ways of thinking about how to integrate research and lessons from both the patient safety and professionalism literature.

In the study by Martinez and colleagues, residents reported witnessing unprofessional...

Personalized Perfect Care

Institute for Healthcare Improvement -

The authors propose measuring quality from the patient’s perspective as an expression of his or her personalized health needs. The Personalized Perfect Care Bundle combines several distinct measures into one and is scored as “all-or-none,” with the patient’s care being counted as complete if he or she has met all of the quality measures for which he or she is eligible.

Nature of Blame in Patient Safety Incident Reports: Mixed Methods Analysis of a National Database

Institute for Healthcare Improvement -

A culture of blame and fear of retribution are recognized barriers to reporting patient safety incidents. This article finds a high frequency of blame in a random sample of safety incident reports in the UK, suggesting that there are still opportunities to shift toward a more systems-focused, blame-free culture in health care.

The Age-Friendly Health System Imperative

Institute for Healthcare Improvement -

The article gives an overview of how five early-adopter US health systems — working in partnership with IHI and The John A. Hartford Foundation as part of the Creating Age-Friendly Health Systems initiative — are testing prototype models for age-friendly care using continuous improvement efforts to streamline and enhance new approaches to geriatric care.

When Patients and Their Families Feel Like Hostages to Health Care

Institute for Healthcare Improvement -

A power imbalance often still exists in the patient-provider relationship, particularly when high-stakes health decisions have to be made. This article explores this dynamic, likening it to “hostage bargaining syndrome” — that is, the patient behaves as if negotiating for their health from a position of fear and confusion -- and suggests ways to counteract this behavior.

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