Quality and Safety in Health Care Journal

Determining the optimal place and time for procedural education

Just-in-time performance support as an educational process

In an apprenticeship model, for a trainee who is developing their skills, situating them in the workplace has distinct advantages. Starting from legitimate peripheral participation, the developing clinician is moulded by social interaction and collaboration while they learn from the spectrum of patients that make up a given clinical population.1 The goal is lasting behavioural and cognitive changes in the trainee as they take up the mantle of ‘expert clinician’.

However, to take on legitimate roles in the clinical workplace, a trainee requires direct just-in-time support, or ‘scaffolding’, in the form of supervision. Their preceptors provide enough support to ensure that safe and successful patient management can be accomplished. This is analogous to training wheels for someone learning to ride a bicycle—a scaffolding mechanism that enables a relative novice to perform the activity from start to finish when they...

Just-in-time simulation-based training

Simulation-based training and assessment in healthcare are now commonplace in the majority of industrialised nations. The role of standardised patients, high-fidelity and low-fidelity manikins, synthetic, animal and virtual reality platforms, and simulation suites, are accepted, and integrated into training curricula in medical and nursing schools, and residency programmes. Despite this widespread use, only a handful of studies have assessed the impact of simulation-based education on patient and health system outcomes, and these studies have their focus on procedural skills such as central line insertion or laparoscopic surgery.1 2 Furthermore, the emphasis of such studies has been on simulation-based education as a tool to impact early learners, with minimal consideration of its use for independent practitioners such as attending physicians and experienced nurses.

An emerging area of simulation-based education is just-in-time training, or as it was termed by Niles et al in 2009, ‘rolling refreshers’, which...

Speaking up about traditional and professionalism-related patient safety threats: a national survey of interns and residents

Background

Open communication between healthcare professionals about care concerns, also known as ‘speaking up’, is essential to patient safety.

Objective

Compare interns' and residents' experiences, attitudes and factors associated with speaking up about traditional versus professionalism-related safety threats.

Design

Anonymous, cross-sectional survey.

Setting

Six US academic medical centres, 2013–2014.

Participants

1800 medical and surgical interns and residents (47% responded).

Measurements

Attitudes about, barriers and facilitators for, and self-reported experience with speaking up. Likelihood of speaking up and the potential for patient harm in two vignettes. Safety Attitude Questionnaire (SAQ) teamwork and safety scales; and Speaking Up Climate for Patient Safety (SUC-Safe) and Speaking Up Climate for Professionalism (SUC-Prof) scales.

Results

Respondents more commonly observed unprofessional behaviour (75%, 628/837) than traditional safety threats (49%, 410/837); p<0.001, but reported speaking up about unprofessional behaviour less commonly (46%, 287/628 vs 71%, 291/410; p<0.001). Respondents more commonly reported fear of conflict as a barrier to speaking up about unprofessional behaviour compared with traditional safety threats (58%, 482/837 vs 42%, 348/837; p<0.001). Respondents were also less likely to speak up to an attending physician in the professionalism vignette than the traditional safety vignette, even when they perceived high potential patient harm (20%, 49/251 vs 71%, 179/251; p<0.001). Positive perceptions of SAQ teamwork climate and SUC-Safe were independently associated with speaking up in the traditional safety vignette (OR 1.90, 99% CI 1.36 to 2.66 and 1.46, 1.02 to 2.09, respectively), while only a positive perception of SUC-Prof was associated with speaking up in the professionalism vignette (1.76, 1.23 to 2.50).

Conclusions

Interns and residents commonly observed unprofessional behaviour yet were less likely to speak up about it compared with traditional safety threats even when they perceived high potential patient harm. Measuring SUC-Safe, and particularly SUC-Prof, may fill an existing gap in safety culture assessment.

Randomised controlled trial to assess the effect of a Just-in-Time training on procedural performance: a proof-of-concept study to address procedural skill decay

Background

A subset of high-risk procedures present significant safety threats due to their (1) infrequent occurrence, (2) execution under time constraints and (3) immediate necessity for patient survival. A Just-in-Time (JIT) intervention could provide real-time bedside guidance to improve high-risk procedural performance and address procedural deficits associated with skill decay.

Objective

To evaluate the impact of a novel JIT intervention on transvenous pacemaker (TVP) placement during a simulated patient event.

Methods

This was a prospective, randomised controlled study to determine the effect of a JIT intervention on performance of TVP placement. Subjects included board-certified emergency medicine physicians from two hospitals. The JIT intervention consisted of a portable, bedside computer-based procedural adjunct. The primary outcome was performance during a simulated patient encounter requiring TVP placement, as assessed by trained raters using a technical skills checklist. Secondary outcomes included global performance ratings, time to TVP placement, number of critical omissions and System Usability Scale scores (intervention only).

Results

Groups were similar at baseline across all outcomes. Compared with the control group, the intervention group demonstrated statistically significant improvement in the technical checklist score (11.45 vs 23.44, p<0.001, Cohen’s d effect size 4.64), the global rating scale (2.27 vs 4.54, p<0.001, Cohen’s d effect size 3.76), and a statistically significant reduction in critical omissions (2.23 vs 0.68, p<0.001, Cohen’s d effect size –1.86). The difference in time to procedural completion was not statistically significant between conditions (11.15 min vs 12.80 min, p=0.12, Cohen’s d effect size 0.65). System Usability Scale scores demonstrated excellent usability.

Conclusion

A JIT intervention improved procedure perfromance, suggesting a role for JIT interventions in rarely performed procedures.

Peers without fears? Barriers to effective communication among primary care physicians and oncologists about diagnostic delays in cancer

Objective

Relatively little attention has been devoted to the role of communication between physicians as a mechanism for individual and organisational learning about diagnostic delays. This study’s objective was to elicit physicians’ perceptions about and experiences with communication among physicians regarding diagnostic delays in cancer.

Design, setting, participants

Qualitative analysis based on seven focus groups. Fifty-one physicians affiliated with three New York-based academic medical centres participated, with six to nine subjects per group. We used content analysis to identify commonalities among primary care physicians and specialists (ie, medical and surgical oncologists).

Primary outcome measure

Perceptions and experiences with physician-to-physician communication about delays in cancer diagnosis.

Results

Our analysis identified five major themes: openness to communication, benefits of communication, fears about giving and receiving feedback, infrastructure barriers to communication and overcoming barriers to communication. Subjects valued communication about cancer diagnostic delays, but they had many concerns and fears about providing and receiving feedback in practice. Subjects expressed reluctance to communicate if there was insufficient information to attribute responsibility, if it would have no direct benefit or if it would jeopardise their existing relationships. They supported sensitive approaches to conveying information, as they feared eliciting or being subject to feelings of incompetence or shame. Subjects also cited organisational barriers. They offered suggestions that might facilitate communication about delays.

Conclusions

Addressing the barriers to communication among physicians about diagnostic delays is needed to promote a culture of learning across specialties and institutions. Supporting open and honest discussions about diagnostic delays may help build safer health systems.

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

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

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

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

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

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

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

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...

The personal and the organisational perspective on iatrogenic harm: bridging the gap through reconciliation processes

A pervasive theme of healthcare reform globally is greater candour about the imperfections of care quality, particularly for patients and family members when things go wrong. Numerous healthcare systems now have published policies around disclosure. However, as Moore and Mello document in their paper in this issue of BMJ Quality and Safety,1 details about how, what and when to disclose are scant, and based on minimal evidence about what works for patients, families, clinicians and organisations. Moore and Mello provide important insights from New Zealand, where a mandatory system for compensation following treatment injuries has been in place for over 40 years, on how to achieve reconciliation that satisfies the concerns of aggrieved patients and carers while being acceptable to clinicians and organisations.

Moore and Mello relate their findings in particular to the North American context. The traditional medical malpractice liability system in the USA has long...

Preventing hospital readmissions: the importance of considering 'impactibility, not just predicted risk

Reducing 28-day or 30-day readmissions has become an important aim for healthcare services, spurred in part by the introduction of financial incentives for hospitals with high readmission rates in the USA, England, Denmark, Germany and elsewhere.1 Unfortunately, many of the most effective interventions are costly, since they are multimodal and involve several components and multiple healthcare practitioners.2 Therefore, some healthcare teams are turning to predictive models in order to identify patients at high risk for readmission and focus resource intensive readmission prevention strategies on such ‘at risk’ patients. Recent years have seen an explosion in these predictive models, which use patterns observed within large data sets to generate readmission risks for individual patients. In 2011, a systematic review found 26 models for readmissions,3 but an updated review that examined papers published up to 2015 found 68 more.4

While doubts remain about...

Keep calm... and prepare

On 22 July 2011, a terrible attack by a lone shooter on the Norwegian island of Utøya cost 77 young lives, injured 78 and changed the lives of hundreds forever within 73 min. In the current international context of increased threat, sharing experience about disaster response is crucial. With some exceptions,1–3 many of these studies adopt a deficit-based analysis approach and focus on dysfunctions rather than positive lessons.

In contrast, Brandrud et al4 adopted an original approach. The group used the conclusions of two official and independent commissions as starting point, namely that the medical response to the incident was particularly well managed. This enabled a ‘positive deviance’5 6 analysis to draw important lessons from this incident.

The authors attempted to gather crucial insights with the help of detailed group interviews and expert review: How did a rural...

Improving reconciliation following medical injury: a qualitative study of responses to patient safety incidents in New Zealand

Background

Despite the investment in exploring patient-centred alternatives to medical malpractice in New Zealand (NZ), the UK and the USA, patients' experiences with these processes are not well understood. We sought to explore factors that facilitate and impede reconciliation following patient safety incidents and identify recommendations for strengthening institution-led alternatives to malpractice litigation.

Methods

We conducted semistructured interviews with 62 patients injured by healthcare in NZ, administrators of 12 public hospitals, 5 lawyers specialising in Accident Compensation Corporation (ACC) claims and 3 ACC staff. NZ was chosen as the research site because it has replaced medical malpractice litigation with a no-fault scheme. Thematic analysis was used to identify key themes from interview transcripts.

Results

Interview responses converged on five elements of the reconciliation process that were important: (1) ask, rather than assume, what patients and families need from the process and recognise that, for many patients, being heard is important and should occur early in the reconciliation process; (2) support timely, sincere, culturally appropriate and meaningful apologies, avoiding forced or tokenistic quasi-apologies; (3) choose words that promote reconciliation; (4) include the people who patients want involved in the reconciliation discussion, including practitioners involved in the harm event; and (5) engage the support of lawyers and patient relations staff as appropriate.

Discussion

Policymakers and healthcare institutions are keenly interested in non-litigation approaches to resolving malpractice incidents. Interviewing participants involved in patient safety incident reconciliation processes suggests that healthcare institutions should not view apology as a substitute for other remedial actions; use flexible guidelines that distil best-practice principles, ensuring that steps are not missed, while not prescribing a ‘one size fits all’ communication approach.

Simplification of the HOSPITAL score for predicting 30-day readmissions

Objective

The HOSPITAL score has been widely validated and accurately identifies high-risk patients who may mostly benefit from transition care interventions. Although this score is easy to use, it has the potential to be simplified without impacting its performance. We aimed to validate a simplified version of the HOSPITAL score for predicting patients likely to be readmitted.

Design and setting

Retrospective study in 9 large hospitals across 4 countries, from January through December 2011.

Participants

We included all consecutively discharged medical patients. We excluded patients who died before discharge or were transferred to another acute care facility.

Measurements

The primary outcome was any 30-day potentially avoidable readmission. We simplified the score as follows: (1) ‘discharge from an oncology division’ was replaced by ‘cancer diagnosis or discharge from an oncology division’; (2) ‘any procedure’ was left out; (3) patients were categorised into two risk groups (unlikely and likely to be readmitted). The performance of the simplified HOSPITAL score was evaluated according to its overall accuracy, its discriminatory power and its calibration.

Results

Thirty-day potentially avoidable readmission rate was 9.7% (n=11 307/117 065 patients discharged). Median of the simplified HOSPITAL score was 3 points (IQR 2–5). Overall accuracy was very good with a Brier score of 0.08 and discriminatory power remained good with a C-statistic of 0.69 (95% CI 0.68 to 0.69). The calibration was excellent when comparing the expected with the observed risk in the two risk categories.

Conclusions

The simplified HOSPITAL score has good performance for predicting 30-day readmission. Prognostic accuracy was similar to the original version, while its use is even easier. This simplified score may provide a good alternative to the original score depending on the setting.

Local emergency medical response after a terrorist attack in Norway: a qualitative study

Introduction

On 22 July 2011, Norway suffered a devastating terrorist attack targeting a political youth camp on a remote island. Within a few hours, 35 injured terrorist victims were admitted to the local Ringerike community hospital. All victims survived. The local emergency medical service (EMS), despite limited resources, was evaluated by three external bodies as successful in handling this crisis. This study investigates the determinants for the success of that EMS as a model for quality improvement in healthcare.

Methods

We performed focus group interviews using the critical incident technique with 30 healthcare professionals involved in the care of the attack victims to establish determinants of the EMS’ success. Two independent teams of professional experts classified and validated the identified determinants.

Results

Our findings suggest a combination of four elements essential for the success of the EMS: (1) major emergency preparedness and competence based on continuous planning, training and learning; (2) crisis management based on knowledge, trust and data collection; (3) empowerment through multiprofessional networks; and (4) the ability to improvise based on acquired structure and competence. The informants reported the successful response was specifically based on multiprofessional trauma education, team training, and prehospital and in-hospital networking including mental healthcare. The powerful combination of preparedness, competence and crisis management built on empowerment enabled the healthcare workers to trust themselves and each other to make professional decisions and creative improvisations in an unpredictable situation.

Conclusion

The determinants for success derived from this qualitative study (preparedness, management, networking, ability to improvise) may be universally applicable to understanding the conditions for resilient and safe healthcare services, and of general interest for quality improvement in healthcare.

Safety and efficiency of a new generic package labelling: a before and after study in a simulated setting

Background

Medication errors are frequent and may cause harm to patients and increase healthcare expenses.

Aim

To explore whether a new labelling influences time and errors when preparing medications in accordance with medication charts in an experimental setting.

Method

We carried out an uncontrolled before and after study with 3 months inbetween experiments. Phase I used original labelling and phase II used new generic labelling. We set up an experimental medicine room, simulating a real-life setting. Twenty-five nurses and ten pharmacy technicians participated in the study. We asked them to prepare medications in accordance with medication charts, place packages on a desk and document the package prepared. We timed the operation. Participants were asked to prepare medications in accordance with as many charts as possible within 30 min.

Results

Nurses prepared significantly more medication charts with the generic labelling compared with the original 3.3 versus 2.6 (p=0.009). Mean time per medication chart was significantly lower with the generic labelling 6.9 min/chart versus 8.5 min/chart (p<0.001). Pharmacy technicians were significantly faster than the nurses in both phase I (6.8 min/chart vs 9.5 min/chart; p<0.001) and phase II (6.1 min/chart vs 7.2 min/chart; p=0.013). The number of errors was low and not significantly different between the two labellings, with errors affecting 9.1% of charts in phase I versus 6.5% in phase II (p=0.5).

Conclusions

A new labelling of medication packages with prominent placement of the active substance(s) and strength(s) in the front of the medication package may reduce time for nurses when preparing medications, without increasing medication errors.

Thematic analysis of US stakeholder views on the influence of labour nurses care on birth outcomes

Background

Childbirth is a leading reason for hospital admission in the USA, and most labour care is provided by registered nurses under physician or midwife supervision in a nurse-managed care model. Yet, there are no validated nurse-sensitive quality measures for maternity care. We aimed to engage primary stakeholders of maternity care in identifying the aspects of nursing care during labour and birth they believe influence birth outcomes, and how these aspects of care might be measured.

Methods

This qualitative study used 15 focus groups to explore perceptions of 73 nurses, 23 new mothers and 9 physicians regarding important aspects of care. Transcripts were analysed thematically. Participants in the final six focus groups were also asked whether or not they thought each of five existing perinatal quality measures were nurse-sensitive.

Results

Nurses, new mothers and physicians identified nurses' support of and advocacy for women as important to birth outcomes. Support and advocacy actions included keeping women and their family members informed, being present with women, setting the emotional tone, knowing and advocating for women's wishes and avoiding caesarean birth. Mothers and nurses took technical aspects of care for granted, whereas physicians discussed this more explicitly, noting that nurses were their ‘eyes and ears’ during labour. Participants endorsed caesarean rates and breastfeeding rates as likely to be nurse-sensitive.

Conclusions

Stakeholder values support inclusion of maternity nursing care quality measures related to emotional support and providing information in addition to physical support and clinical aspects of care. Care models that ensure labour nurses have sufficient time and resources to engage in the supportive relationships that women value might contribute to better health outcomes and improved patient experience.

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