An enduring challenge for the improvement of healthcare quality is variation in the success of quality improvement (QI) interventions when implemented across settings.1 This is particularly true in the field of healthcare-associated infection (HAI) prevention. Some of the brightest success stories in QI have emerged from large-scale efforts to reduce HAIs such as central venous catheter-related bloodstream infections (CRBSIs)2 or catheter-associated urinary tract infections.3 The light dims, however, when efforts to export these interventions to other settings fail to meaningfully improve outcomes.4 5
To make sense of this phenomenon, attention must be paid to the social, organisational, economic, and cultural factors that may shape the observed associations between interventions and their outcomes.1 6–8 These factors are components of context, which is a key modifier of the impact of QI interventions.
The pace of technological advancements in the intensive care unit (ICU) challenges clinicians’ ability to manage ethical and decision-making challenges near the end of life. Modern medicine has advanced to the point where we can support multiple organ systems simultaneously and sustain life when the benefits of treatments to overall survival and quality of life are not always clear. Physiological and technological limits no longer always tell us when to stop, and clinicians and families are now forced to take over the role that was once played by nature to make decisions as to whether and when life-sustaining therapies should be withdrawn or withheld.
Unfortunately, we often do not do a very good job of making these tough decisions even when patients can participate in the discussion. To add to that challenge, patients often lack decision-making capacity during their ICU stay. Clinicians and families struggle to balance the inherently imperfect practice...
The Prevention of Hospital Infections by Intervention and Training (PROHIBIT) project included a cluster-randomised, stepped wedge, controlled study to evaluate multiple strategies to prevent catheter-related bloodstream infection. We report an in-depth investigation of the main barriers, facilitators and contextual factors relevant to successfully implementing these strategies in European acute care hospitals.Methods
Qualitative comparative case study in 6 of the 14 European PROHIBIT hospitals. Data were collected through interviews with key stakeholders and ethnographic observations conducted during 2-day site visits, before and 1 year into the PROHIBIT intervention. Qualitative measures of implementation success included intervention fidelity, adaptation to local context and satisfaction with the intervention programme.Results
Three meta-themes emerged related to implementation success: ‘implementation agendas’, ‘resources’ and ‘boundary-spanning’. Hospitals established unique implementation agendas that, while not always aligned with the project goals, shaped subsequent actions. Successful implementation required having sufficient human and material resources and dedicated change agents who helped make the intervention an institutional priority. The salary provided for a dedicated study nurse was a key facilitator. Personal commitment of influential individuals and boundary spanners helped overcome resource restrictions and intrainstitutional segregation.Conclusion
This qualitative study revealed patterns across cases that were associated with successful implementation. Consideration of the intervention–context relation was indispensable to understanding the observed outcomes.
Literature depicts differences in ethical decision-making (EDM) between countries and intensive care units (ICU).Objectives
To better conceptualise EDM climate in the ICU and to validate a tool to assess EDM climates.Methods
Using a modified Delphi method, we built a theoretical framework and a self-assessment instrument consisting of 35 statements. This Ethical Decision-Making Climate Questionnaire (EDMCQ) was developed to capture three EDM domains in healthcare: interdisciplinary collaboration and communication; leadership by physicians; and ethical environment. This instrument was subsequently validated among clinicians working in 68 adult ICUs in 13 European countries and the USA. Exploratory and confirmatory factor analysis was used to determine the structure of the EDM climate as perceived by clinicians. Measurement invariance was tested to make sure that variables used in the analysis were comparable constructs across different groups.Results
Of 3610 nurses and 1137 physicians providing ICU bedside care, 2275 (63.1%) and 717 (62.9%) participated respectively. Statistical analyses revealed that a shortened 32-item version of the EDMCQ scale provides a factorial valid measurement of seven facets of the extent to which clinicians perceive an EDM climate: self-reflective and empowering leadership by physicians; practice and culture of open interdisciplinary reflection; culture of not avoiding end-of-life decisions; culture of mutual respect within the interdisciplinary team; active involvement of nurses in end-of-life care and decision-making; active decision-making by physicians; and practice and culture of ethical awareness. Measurement invariance of the EDMCQ across occupational groups was shown, reflecting that nurses and physicians interpret the EDMCQ items in a similar manner.Conclusions
The 32-item version of the EDMCQ might enrich the EDM climate measurement, clinicians’ behaviour and the performance of healthcare organisations. This instrument offers opportunities to develop tailored ICU team interventions.
Hospital admission, like hospital discharge, represents a transition of care associated with changes in setting, healthcare providers and clinical management. While considerable efforts have focused on improving the quality and safety of hospital-to-home transitions, there has been little focus on transitions into hospital.Objectives
Among children hospitalised with ambulatory care sensitive conditions, we aimed to characterise families’ experiences as they transitioned from outpatient to inpatient care, identify hospital admission processes and outcomes most important to families and determine how parental perspectives differed between children admitted directly and through emergency departments (ED).Methods
We conducted semistructured interviews with parents of hospitalised children at four structurally diverse hospitals. We inquired about preadmission healthcare encounters, how hospital admission decisions were made and parents’ preferences regarding hospital admission processes and outcomes. Interviews were transcribed verbatim and analysed using a general inductive approach.Results
We conducted 48 interviews. Participants were predominantly mothers (74%); 45% had children with chronic illnesses and 52% were admitted directly. Children had a median of two (IQR 1–3) healthcare encounters in the week preceding hospital admission, with 44% seeking care in multiple settings. Patterns of healthcare utilisation were influenced by (1) disease acuity and healthcare access; (2) past experiences; and (3) varied perspectives about primary care and ED roles as hospital gatekeepers. Participants’ hospital admission priorities included: (1) effective clinical care; (2) efficient admission processes; (3) safety and security; (4) timeliness; and (5) patient and family-centred processes of care.Conclusions
Families received preadmission care in several settings and described varying degrees of care coordination during their admission processes. This research can guide improvements in hospitals’ admission systems, necessary to achieve health system integration and continuity of care.
To evaluate the effectiveness of a brief mindfulness intervention on hand hygiene performance and mindful attention for inpatient physician teams.Design
A pilot, pre-test/post-test randomised controlled mixed methods trial.Setting
One academic medical centre in the USA.Participants
Four internal medicine physician teams consisting of one attending, one resident, two to three interns and up to four medical students.Intervention
A facilitated, group-based educational discussion on how mindfulness, as practised through mindful hand hygiene, may improve clinical care and practices in the hospital setting.Main outcomes and measures
The primary outcome was hand hygiene adherence (percentage) for each patient encounter. Other outcomes were observable mindful moments and mindful attention, measured using the Mindfulness Attention Awareness Scale, from baseline to post-intervention, and qualitative evaluation of the intervention.Results
For attending physicians, hand hygiene adherence increased 14.1% in the intervention group compared with a decrease of 5.7% in the controls (P=0.035). For residents, the comparable figures were 24.7% (intervention) versus 0.2% (control) (P=0.064). For interns, adherence increased 10.0% with the intervention versus 4.2% in the controls (P=0.007). For medical students, adherence improved more in the control group (4.7% intervention vs 7.7% controls; P=0.003). An increase in mindfulness behaviours was observed for the intervention group (3.7%) versus controls (0.9%) (P=0.021). Self-reported mindful attention did not change (P=0.865).Conclusions
A brief, education-based mindfulness intervention improved hand hygiene in attending physicians and residents, but not in medical students. The intervention was well-received, increased mindfulness practice, and appears to be a feasible way to introduce mindfulness in the clinical setting. Future work instructing clinicians in mindfulness to improve hand hygiene may prove valuable.Trial registration number
Nursing management is considered important for patient safety. Prior research has predominantly focused on charismatic leadership styles, although it is questionable whether these best characterise the role of nurse managers. Managerial control is also relevant. Therefore, we aimed to develop and test a measurement instrument for control-based and commitment-based safety management of nurse managers in clinical hospital departments.Methods
A cross-sectional survey design was used to test the newly developed questionnaire in a sample of 2378 nurses working in clinical departments. The nurses were asked about their perceptions of the leadership behaviour and management practices of their direct supervisors. Psychometric properties were evaluated using confirmatory factor analysis and reliability estimates.Results
The final 33-item questionnaire showed acceptable goodness-of-fit indices and internal consistency (Cronbach’s α of the subscales range: 0.59–0.90). The factor structure revealed three subdimensions for control-based safety management: (1) stressing the importance of safety rules and regulations; (2) monitoring compliance; and (3) providing employees with feedback. Commitment-based management consisted of four subdimensions: (1) showing role modelling behaviour; (2) creating safety awareness; (3) showing safety commitment; and (4) encouraging participation. Construct validity of the scale was supported by high factor loadings and provided preliminary evidence that control-based and commitment-based safety management are two distinct yet related constructs. The findings were reconfirmed in a cross-validation procedure.Conclusion
The results provide initial support for the construct validity and reliability of our ConCom Safety Management Scale. Both management approaches were found to be relevant for managing patient safety in clinical hospital departments. The scale can be used to deepen our understanding of the influence of patient safety management on healthcare professionals’ safety behaviour as well as patient safety outcomes.
The Measurement and Monitoring of Safety Framework provides a conceptual model to guide organisations in assessing safety. The Health Foundation funded a large-scale programme to assess the value and impact of applying the Framework in regional and frontline care settings. We explored the experiences and reflections of key participants in the programme.Methods
The study was conducted in the nine healthcare organisations in England and Scotland testing the Framework (three regional improvement bodies, six frontline settings). Post hoc interviews with clinical and managerial staff were analysed using template analysis.Findings
Participants reported that the Framework promoted a substantial shift in their thinking about how safety is actively managed in their environment. It provided a common language, facilitated a more inquisitive approach and encouraged a more holistic view of the components of safety. These changes in conceptual understanding, however, did not always translate into broader changes in practice, with many sites only addressing some aspects of the Framework. One of the three regions did embrace the Framework in its entirety and achieved wider impact with a range of interventions. This region had committed leaders who took time to fully understand the concepts, who maintained a flexible approach to exploring the utility of the Framework and who worked with frontline staff to translate the concepts for local settings.Conclusions
The Measuring and Monitoring of Safety Framework has the potential to support a broader and richer approach to organisational safety. Such a conceptually based initiative requires both committed leaders who themselves understand the concepts and more time to establish understanding and aims than might be needed in a standard improvement programme.
To determine frequencies of healthcare workers (HCWs) speak up-related behaviours and the association of speak up-related safety climate with speaking up and withholding voice.Design
Cross-sectional survey of doctors and nurses. Data were analysed using multilevel logistic regression modelsSetting
4 hospitals with a total of nine sites from the German, French and Italian speaking part of Switzerland.Participants
Survey data were collected from 979 nurses and doctors.Main outcome measures
Frequencies of perceived patient safety concerns, of withholding voice and of speaking up behaviour. Speak up-related climate measures included psychological safety, encouraging environment and resignation.Results
Perceived patient safety concerns were frequent among doctors and nurses (between 62% and 80% reported at least one safety concern during the last 4 weeks depending on the single items). Withholding voice was reported by 19%–39% of HCWs. Speaking up was reported by more than half of HCWs (55%–76%). The frequency of perceived concerns during the last 4 weeks was positively associated with both speaking up (OR=2.7, p<0.001) and withholding voice (OR=1.6, p<0.001). An encouraging environment was related to higher speaking up frequency (OR=1.3, p=0.005) and lower withholding voice frequency (OR=0.82, p=0.006). Resignation was associated with withholding voice (OR=1.5, p<0.001). The variance in both voicing behaviours attributable to the hospital-site level was marginal.Conclusions
Our results strengthen the importance of a speak up-supportive safety climate for staff safety-related communication behaviours, specifically withholding voice. This study indicates that a poor climate, in particular high levels of resignation among HCWs, is linked to frequent ‘silence’ of HCWs but not inversely associated with frequent speaking up. Interventions addressing safety-related voicing behaviours should discriminate between withholding voice and speaking up.
Rounding checklists are an increasingly common quality improvement tool in the intensive care unit (ICU). However, effectiveness studies have shown conflicting results. We sought to understand ICU providers’ perceptions of checklists, as well as barriers and facilitators to effective utilisation of checklists during daily rounds.Objectives
To understand how ICU providers perceive rounding checklists and develop a framework for more effective rounding checklist implementation.Methods
We performed a qualitative study in 32 ICUs within 14 hospitals in a large integrated health system in the USA. We used two complementary data collection methods: direct observation of daily rounds and semistructured interviews with ICU clinicians. Observations and interviews were thematically coded and primary themes were identified using a combined inductive and deductive approach.Results
We conducted 89 interviews and performed 114 hours of observation. Among study ICUs, 12 used checklists and 20 did not. Participants described the purpose of rounding checklists as a daily reminder for evidence-based practices, a tool for increasing shared understanding of patient care across care providers and a way to increase the efficiency of rounds. Checklists were perceived as not helpful when viewed as overstandardising care and when they are not relevant to a particular ICU’s needs. Strategies to improve checklist implementation include attention to the brevity and relevance of the checklist to the particular ICU, consistent use over time, and integration with daily work flow.Conclusion
Our results provide potential insights about why ICU rounding checklists frequently fail to improve outcomes and offer a framework for effective checklist implementation through greater feedback and accountability.