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We want to know: patient comfort speaking up about breakdowns in care and patient experience

Quality and Safety in Health Care Journal -

Objective

To assess patient comfort speaking up about problems during hospitalisation and to identify patients at increased risk of having a problem and not feeling comfortable speaking up.

Design

Cross-sectional study.

Setting

Eight hospitals in Maryland and Washington, District of Columbia.

Participants

Patients hospitalised at any one of eight hospitals who completed the Hospital Consumer Assessment of Healthcare Providers and Systems survey postdischarge.

Main outcome measures

Response to the question ‘How often did you feel comfortable speaking up if you had any problems in your care?’ grouped as: (1) no problems during hospitalisation, (2) always felt comfortable speaking up and (3) usually/sometimes/never felt comfortable speaking up.

Results

Of 10 212 patients who provided valid responses, 4958 (48.6%) indicated they had experienced a problem during hospitalisation. Of these, 1514 (30.5%) did not always feel comfortable speaking up. Predictors of having a problem during hospitalisation included age, health status and education level. Patients who were older, reported worse overall and mental health, were admitted via the Emergency Department and did not speak English at home were less likely to always feel comfortable speaking up. Patients who were not always comfortable speaking up provided lower ratings of nurse communication (47.8 vs 80.4; p<0.01), physician communication (57.2 vs 82.6; p<0.01) and overall hospital ratings (7.1 vs 8.7; p<0.01). They were significantly less likely to definitely recommend the hospital (36.7% vs 71.7 %; p<0.01) than patients who were always comfortable speaking up.

Conclusions

Patients frequently experience problems in care during hospitalisation and many do not feel comfortable speaking up. Creating conditions for patients to be comfortable speaking up may result in service recovery opportunities and improved patient experience. Such efforts should consider the impact of health literacy and mental health on patient engagement in patient-safety activities.

Explaining organisational responses to a board-level quality improvement intervention: findings from an evaluation in six providers in the English National Health Service

Quality and Safety in Health Care Journal -

Background

Healthcare systems worldwide are concerned with strengthening board-level governance of quality. We applied Lozeau, Langley and Denis’ typology (transformation, customisation, loose coupling and corruption) to describe and explain the organisational response to an improvement intervention in six hospital boards in England.

Methods

We conducted fieldwork over a 30-month period as part of an evaluation in six healthcare provider organisations in England. Our data comprised board member interviews (n=54), board meeting observations (24 hours) and relevant documents.

Results

Two organisations transformed their processes in a way that was consistent with the objectives of the intervention, and one customised the intervention with positive effects. In two further organisations, the intervention was only loosely coupled with organisational processes, and participation in the intervention stopped when it competed with other initiatives. In the final case, the intervention was corrupted to reinforce existing organisational processes (a focus on external regulatory requirements). The organisational response was contingent on the availability of ‘slack’—expressed by participants as the ‘space to think’ and ‘someone to do the doing’—and the presence of a functioning board.

Conclusions

Underperforming organisations, under pressure to improve, have little time or resources to devote to organisation-wide quality improvement initiatives. Our research highlights the need for policy-makers and regulators to extend their focus beyond the choice of intervention, to consider how the chosen intervention will be implemented in public sector hospitals, how this will vary between contexts and with what effects. We provide useful information on the necessary conditions for a board-level quality improvement intervention to have positive effects.

Low-value care in Australian public hospitals: prevalence and trends over time

Quality and Safety in Health Care Journal -

Objective

To examine 27 low-value procedures, as defined by international recommendations, in New South Wales public hospitals.

Design

Analysis of admitted patient data for financial years 2010–2011 to 2016–2017.

Main outcome measures

Number and proportion of episodes identified as low value by two definitions (narrower and broader), associated costs and bed-days, and variation between hospitals in financial year 2016–2017; trends in numbers of low-value episodes from 2010–2011 to 2016–2017.

Results

For 27 procedures in 2016–2017, we identified 5079 (narrower definition) to 8855 (broader definition) episodes involving low-value care (11.00%–19.18% of all 46 169 episodes involving these services). These episodes were associated with total inpatient costs of $A49.9 million (narrower) to $A99.3 million (broader), which was 7.4% (narrower) to 14.7% (broader) of the total $A674.6 million costs for all episodes involving these procedures in 2016–2017, and involved 14 348 (narrower) to 29 705 (broader) bed-days. Half the procedures accounted for less than 2% of all low-value episodes identified; three of these had no low-value episodes in 2016–2017. The proportion of low-value care varied widely between hospitals. Of the 14 procedures accounting for most low-value care, seven showed decreasing trends from 2010–2011 to 2016–2017, while three (colonoscopy for constipation, endoscopy for dyspepsia, sentinel lymph node biopsy for melanoma in situ) showed increasing trends.

Conclusions

Low-value care in this Australian public hospital setting is not common for most of the measured procedures, but colonoscopy for constipation, endoscopy for dyspepsia and sentinel lymph node biopys for melanoma in situ require further investigation and action to reverse increasing trends. The variation between procedures and hospitals may imply different drivers and potential remedies.

Facilitators of interdepartmental quality improvement: a mixed-methods analysis of a collaborative to improve pediatric community-acquired pneumonia management

Quality and Safety in Health Care Journal -

Background

Emergency medicine and paediatric hospital medicine physicians each provide a portion of the initial clinical care for the majority of hospitalised children in the USA. While these disciplines share goals to increase quality of care, there are scant data describing their collaboration. Our national, multihospital learning collaborative, which aimed to increase narrow-spectrum antibiotic prescribing for paediatric community-acquired pneumonia, provided an opportunity to examine factors influencing the success of quality improvement efforts across these two clinical departments.

Objective

To identify barriers to and facilitators of interdepartmental quality improvement implementation, with a particular focus on increasing narrow-spectrum antibiotic use in the emergency department and inpatient settings for children hospitalised with pneumonia.

Methods

We used a mixed-methods design, analysing interviews, written reports and quality measures. To describe hospital characteristics and quality measures, we calculated medians/IQRs for continuous variables, frequencies for categorical variables and Pearson correlation coefficients. We conducted in-depth, semistructured interviews by phone with collaborative site leaders; interviews were transcribed verbatim and, with progress reports, analysed using a general inductive approach.

Results

47 US-based hospitals were included in this analysis. Qualitative analysis of 35 interview transcripts and 142 written reports yielded eight inter-related domains that facilitated successful interdepartmental quality improvement: (1) hospital leadership and support, (2) quality improvement champions, (3) evidence supporting the intervention, (4) national health system influences, (5) collaborative culture, (6) departments’ structure and resources, (7) quality improvement implementation strategies and (8) interdepartmental relationships.

Conclusions

The conceptual framework presented here may be used to identify hospitals’ strengths and potential barriers to successful implementation of quality improvement efforts across clinical departments.

Sicker patients account for the weekend mortality effect among adult emergency admissions to a large hospital trust

Quality and Safety in Health Care Journal -

Objective

To determine whether the higher weekend admission mortality risk is attributable to increased severity of illness.

Design

Retrospective analysis of 4 years weekend and weekday adult emergency admissions to a university teaching hospital in England.

Outcome measures

30-day postadmission weekend:weekday mortality ratios adjusted for severity of illness (baseline National Early Warning Score (NEWS)), routes of admission to hospital, transfer to the intensive care unit (ICU) and demographics.

Results

Despite similar emergency department daily attendance rates, fewer patients were admitted on weekends (mean admission rate 91/day vs 120/day) because of fewer general practitioner referrals. Weekend admissions were sicker than weekday (mean NEWS 1.8 vs 1.7, p=0.008), more likely to undergo transfer to ICU within 24 hours (4.2% vs 3.0%), spent longer in hospital (median 3 days vs 2 days) and less likely to experience same-day discharge (17.2% vs 21.9%) (all p values <0.001).

The crude 30-day postadmission mortality ratio for weekend admission (OR=1.13; 95% CI 1.08 to 1.19) was attenuated using standard adjustment (OR=1.11; 95% CI 1.05 to 1.17). In patients for whom NEWS values were available (90%), the crude OR (1.07; 95% CI 1.01 to 1.13) was not affected with standard adjustment. Adjustment using NEWS alone nullified the weekend effect (OR=1.02; 0.96–1.08).

NEWS completion rates were higher on weekends (91.7%) than weekdays (89.5%). Missing NEWS was associated with direct transfer to intensive care bypassing electronic data capture. Missing NEWS in non-ICU weekend patients was associated with a higher mortality and fewer same-day discharges than weekdays.

Conclusions

Patients admitted to hospital on weekends are sicker than those admitted on weekdays. The cause of the weekend effect may lie in community services.

Artificial intelligence, bias and clinical safety

Quality and Safety in Health Care Journal -

Introduction

In medicine, artificial intelligence (AI) research is becoming increasingly focused on applying machine learning (ML) techniques to complex problems, and so allowing computers to make predictions from large amounts of patient data, by learning their own associations.1 Estimates of the impact of AI on the wider economy globally vary wildly, with a recent report suggesting a 14% effect on global gross domestic product by 2030, half of which coming from productivity improvements.2 These predictions create political appetite for the rapid development of the AI industry,3 and healthcare is a priority area where this technology has yet to be exploited.2 3 The digital health revolution described by Duggal et al4 is already in full swing with the potential to ‘disrupt’ healthcare. Health AI research has demonstrated some impressive results,5–10

Framing the challenges of artificial intelligence in medicine

Quality and Safety in Health Care Journal -

On a clear January morning in Florida, a Tesla enthusiast and network entrepreneur was driving his new Tesla Model S on US Highway 27A, returning from a family trip. He had posted dozens of widely circulated YouTube tutorial videos on his vehicle and clearly understood many of the technical details of his car. That day, he let the vehicle run autonomously on Autopilot mode for 37 min, before it crashed into the trailer of a truck turning left. The Autopilot did not identify the white side of the trailer as a potential hazard, and the driver was killed, leaving his family and his high-tech business behind.1 This tragedy is not a metaphor for artificial intelligence (AI) applications but an example of a long-recognised challenge in AI: the Frame Problem.2 Although rarely appreciated in the scholarly and lay descriptions of the stunning recent successes of AI...

Redesigning care: adapting new improvement methods to achieve person-centred care

Quality and Safety in Health Care Journal -

In many industries, meeting the needs of customers can mean the difference between thriving and going out of business. In the last century, manufacturers started to use and refine methods to reliably make products that offered a better customer experience at lower cost, by reducing defects and waste.1 These methods, introduced to healthcare almost 30 years ago2, are now part of the routine operations of many hospitals and large physician organisations. They have contributed to improvements in patient experience, reductions in hospital acquired infections and fewer readmissions.3 Customer-focused companies have not stood still during this time, creating an abundance of new products and services.4 5Many of these were made by technology startups and firms adapting industrial design methods like ‘human-centred design’ to create better experiences by understanding and responding to unspoken or unmet needs of customers.6 Embracing...

Quality & safety in the literature: March 2019

Quality and Safety in Health Care Journal -

Healthcare quality and safety spans 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 6 months. Some articles will focus on a particular theme, while others will highlight unique publications from high impact medical journals.

Key points

  • Removal of financial quality-of-care incentives was associated with an immediate and persistent decline in documented quality indicators in comparison to those in which financial incentives remained. NEJM. 6 September 2018.

  • Hospital-at-home care bundled with a 30-day postacute transitional care programme resulted in a statistically significant reduction in length of stay, decreased odds of readmission, emergency department visit, and admission to skilled nursing facility, and increased patient satisfaction scores without increased adverse events. JAMA IM. 1 August 2018.

  • ...
  • Sentinel lymph node biopsy for in situ melanoma is unlikely in Australia

    Quality and Safety in Health Care Journal -

    We commend Badgery-Parker and colleagues for their comprehensive review of ‘low-value’ healthcare provided at public hospitals in New South Wales (NSW), Australia and support their initiative to identify low-value care.1 In relation to melanoma in situ, we agree completely with the Evaluating Evidence Enhancing Efficiences (EVOLVE) guidelines2 that there is no evidence that sentinel node (SN) biopsy for this entity is beneficial and also agree that it would constitute low-value care if performed. However, there appears to be a serious methodological flaw in the study by Badgery-Parker et al which may have led to the erroneous claim that SN biopsy for melanoma in situ is being performed in NSW public hospitals and ‘requires action to reverse increasing trends’.

    The authors used public hospital admitted-patient data to identify SN biopsy procedures and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification codes...

    Response to: 'Sentinel lymph node biopsy for in situ melanoma is unlikely in Australia by Morton and Thompson

    Quality and Safety in Health Care Journal -

    We thank Drs Morton and Thompson1 for their comments on our indicator for low-value sentinel lymph node biopsy (SLNB). They provide a plausible explanation for our finding that SLNB appears to be used for melanoma in situ in public hospitals in New South Wales (NSW). Their explanation is based on an understanding of care processes that cannot be inferred from our data. We hoped to gain such understanding through our clinician workshop, for which invitations were sent out widely through various channels. We agree it is unfortunate that no dermatologists, pathologists or oncologists chose to participate.

    Morton and Thompson suggest that melanoma in situ is recorded when a wide-excision specimen is taken from a site that was previously biopsied and found to have invasive melanoma. If the wide-area specimen has residual melanoma in situ, this diagnosis is recorded, while the SLNB is done because of the earlier...

    What Is Age-Friendly Health Care?

    Institute for Healthcare Improvement -

    In this article, Alice Bonner provides commentary on IHI's Age-Friendly Health Systems initiative. “Age friendly is about older adults, but it’s also really about families and communities. Age friendly means a health system that is supportive and leads to good health outcomes for people at any age — not just older adults,” says Alice Bonner.

    Health Care Programs for Older Adults

    Institute for Healthcare Improvement -

    Age-Friendly Health Systems (AFHS), in partnership with the Institute for Healthcare Improvement, has been growing. Five pioneering systems are currently in place with another 75 coming onboard around the US. The foundation’s goal is to have 20 percent of health systems nationwide “Age-Friendly” by 2020.

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