In their article in this issue of BMJ Quality and Safety, ‘We listened and depended on and supported each other’, Ginsburg et al examine how leaders shaped the site-level experience in a quality improvement collaborative aimed at improving safety in long-term elder care.1 They performed a secondary thematic analysis of an existing mixed-methods data set generated from over 150 leaders and staff at 31 sites, where the qualitative data describing leadership processes included written materials, observations, survey responses and focus groups. The research team had previously reported that participants’ perceptions of leader support correlated with success to an even greater extent than their perceptions of the intervention itself.2 In the additional analysis presented in this issue, the actions of effective leaders are described in three thematic areas: developing commitment, creating learning capacity and nurturing relationships.

The authors assert that relatively little is known about the...

Programmes dedicated to driving improvement in healthcare quality have grown dramatically in the last two decades. Accreditation programmes along with performance measurement and reporting have been central to these efforts. In the USA, public reporting with financial rewards and penalties has been tied to results driving a proliferation of hundreds of quality measures across dozens of programmes at every level of healthcare. Measures are now routinely included in contracts that government and commercial payers establish with delivery organisations. Many of these measures, designed to evaluate the quality of care for large populations, have been applied to measure the quality of ambulatory practice groups and even individual clinicians with little attention to the statistical validity or utility of the results.

A backlash against performance measurement has gained momentum in recent years. Clinicians and policymakers are increasingly questioning the value of such programmes. Sceptics highlight three concerns. First is the financial...

Pain is a leading cause of disease burden and ill health globally, affecting approximately one in five people.1 Opioid analgesics are deemed essential medicines owing to their ability to relieve pain and dyspnoea.2 However, they are also recognised as high-risk medicines due to their propensity for harm, including adverse effects, dependence, non-medical use and overdose.3 Globally, significant variations in opioid access and usage have been observed. In 2018–2020, many countries in Asia and Africa consumed fewer than 200 standard defined daily doses of opioids per million inhabitants per day.4 Yet, in the same period, the USA consumed an average of over 20 000 standard defined daily doses per million inhabitants per day.4 While medical needs will inevitably vary between countries according to their epidemiological profiles, the magnitude of disparity in consumption indicates potential unmet need in some countries and overuse...

Background

There is growing recognition in the literature of the ‘Herculean’ efforts required to bring about change in healthcare processes and systems. Leadership is recognised as a critical lever for implementation of quality improvement (QI) and other complex team-level interventions; however, the processes by which leaders facilitate change are not well understood. The aim of this study is to examine ‘how’ leadership influences implementation of QI interventions.

Methods

We drew on the leadership literature and used secondary data collected as part of a process evaluation of the Safer Care for Older Persons in residential Environments (SCOPE) QI intervention to gain insights regarding the processes by which leadership influences QI implementation. Specifically, using detailed process evaluation data from 31 unit-based nursing home teams we conducted a thematic analysis with a codebook developed a priori based on the existing literature to identify leadership processes.

Results

Effective leaders (ie, those who care teams felt supported by and who facilitated SCOPE implementation) successfully developed and reaffirmed teams’ commitment to the SCOPE QI intervention (theme 1), facilitated learning capacity by fostering follower participation in SCOPE and empowering care aides to step into team leadership roles (theme 2) and actively supported team-oriented processes where they developed and nurtured relationships with their followers and supported them as they navigated relationships with other staff (theme 3). Together, these were the mechanisms by which care aides were brought on board with the intervention, stayed on board and, ultimately, transplanted the intervention into the facility. Building learning capacity and creating a culture of improvement are thought to be the overarching processes by which leadership facilitates implementation of complex interventions like SCOPE.

Conclusions

Results highlight important, often overlooked, relational and sociocultural aspects of successful QI leadership in nursing homes that can guide the design, implementation and scaling of complex interventions and can guide future research.

Background

The number of quality indicators for which clinicians need to record data is increasing. For many indicators, there are concerns about their efficacy. This study aimed to determine whether working with only a consensus-based core set of quality indicators in the intensive care unit (ICU) reduces the time spent on documenting performance data and administrative burden of ICU professionals, and if this is associated with more joy in work without impacting the quality of ICU care.

Methods

Between May 2021 and June 2023, ICU clinicians of seven hospitals in the Netherlands were instructed to only document data for a core set of quality indicators. Time spent on documentation, administrative burden and joy in work were collected at three time points with validated questionnaires. Longitudinal data on standardised mortality rates (SMR) and ICU readmission rates were gathered from the Dutch National Intensive Care registry. Longitudinal effects and differences in outcomes between ICUs and between nurses and physicians were statistically tested.

Results

A total of 390 (60%), 291 (47%) and 236 (40%) questionnaires returned at T0, T1 and T2. At T2, the overall median time spent on documentation per day was halved by 30 min (p<0.01) and respondents reported fewer unnecessary and unreasonable administrative tasks (p<0.01). Almost one-third still experienced unnecessary administrative tasks. No significant changes over time were found in joy in work, SMR and ICU readmission.

Conclusions

Implementing a core set of quality indicators reduces the time ICU clinicians spend on documentation and administrative burden without negatively affecting SMR or ICU readmission rates. Time savings can be invested in patient care and improving joy in work in the ICU.

Background and objectives

Methods

A structured search strategy encompassing databases including MEDLINE, Embase, CINAHL Plus, PsycINFO and Cochrane Library was implemented from inception to October 2023. Included studies focused on interventions targeting opioid reduction in adults following major surgeries. The risk of bias was evaluated using Cochrane risk-of-bias tool V.2 (RoB 2) and non-randomised studies of interventions (ROBINS-I) tools, and Cohen’s d effect sizes were calculated. BCTs were identified using a validated taxonomy.

Results

22 studies, comprising 7 clinical trials and 15 cohort studies, were included, with varying risks of bias. Educational (n=12), guideline-focused (n=3), multifaceted (n=5) and pharmacist-led (n=2) interventions demonstrated diverse effect sizes (small-medium n=10, large n=12). A total of 23 unique BCTs were identified across studies, occurring 140 times. No significant association was observed between the number of BCTs and effect size, and interventions with large effect sizes predominantly targeted healthcare professionals. Key BCTs in interventions with the largest effect sizes included behaviour instructions, behaviour substitution, goal setting (outcome), social support (practical), social support (unspecified), pharmacological support, prompts/cues, feedback on behaviour, environmental modification, graded tasks, outcome goal review, health consequences information, action planning, social comparison, credible source, outcome feedback and social reward.

Conclusions

Understanding the dominant BCTs in highly effective interventions provides valuable insights for future opioid tapering strategy implementations. Further research and validation are necessary to establish associations between BCTs and effectiveness, considering additional influencing factors.

PROSPERO registration number

CRD42022290060.

Background

Urinary tract infection (UTI) is the most diagnosed infection in older people living in care homes.

Objective

To identify interventions for recognising and preventing UTI in older people living in care homes in the UK and explain the mechanisms by which they work, for whom and under what circumstances.

Methods

A realist synthesis of evidence was undertaken to develop programme theory underlying strategies to recognise and prevent UTI. A generic topic-based search of bibliographic databases was completed with further purposive searches to test and refine the programme theory in consultation with stakeholders.

Results

56 articles were included in the review. Nine context–mechanism–outcome configurations were developed and arranged across three theory areas: (1) Strategies to support accurate recognition of UTI, (2) care strategies for residents to prevent UTI and (3) making best practice happen. Our programme theory explains how care staff can be enabled to recognise and prevent UTI when this is incorporated into care routines and activities that meet the fundamental care needs and preferences of residents. This is facilitated through active and visible leadership by care home managers and education that is contextualised to the work and role of care staff.

Conclusions

Care home staff have a vital role in preventing and recognising UTI in care home residents.

Incorporating this into the fundamental care they provide can help them to adopt a proactive approach to preventing infection and avoiding unnecessary antibiotic use. This requires a context of care with a culture of personalisation and safety, promoted by commissioners, regulators and providers, where leadership and resources are committed to support preventative action by knowledgeable care staff.

Objective

Diagnostic delay is a pervasive patient safety problem that disproportionately affects historically underserved populations. We aim to systematically examine and synthesise published qualitative studies on patient experiences with diagnostic delay among historically underserved racial and ethnic populations.

Data sources

PubMed.

Eligibility criteria

Primary qualitative studies detailing patient or caregiver-reported accounts of delay in the diagnosis of a disease among underserved racial and ethnic populations; conducted in the USA; published in English in a peer-reviewed journal (years 2012–2022); study cohort composed of >50% non-white racial and ethnic populations.

Data analysis

Primary outcomes were barriers to timely diagnosis of a disease. Screening and thematic abstraction were performed independently by two investigators, and data were synthesised using the ‘Model of Pathways to Treatment’ conceptual framework.

Results

Sixteen studies from multiple clinical domains were included. Barriers to timely diagnosis emerged at the socioeconomic and sociocultural level (low health literacy, distrust in healthcare systems, healthcare avoidance, cultural and linguistic barriers), provider level (cognitive biases, breakdown in patient-provider communication, lack of disease knowledge) and health systems level (inequity in organisational health literacy, administrative barriers, fragmented care environment and a lack of organisational cultural competence). None of the existing studies explored diagnostic disparities among Asian Americans/Pacific Islanders, and few examined chronic conditions known to disproportionately affect historically underserved populations.

Discussion

Historically underserved racial and ethnic patients encountered many challenges throughout their diagnostic journey. Systemic strategies are needed to address and prevent diagnostic disparities.

Measuring the quality of healthcare has become increasingly important, with surgery not exempt from such evaluation. As technological opportunities and novel developments broaden the range and complexity of treatments that can be offered, the strain on resources is increasing in most healthcare systems worldwide. This is particularly the case for universal healthcare systems, where the budget is based on an allowance and care is given on a needs-based assumption. Thus, the quest of measuring what is done and how well is driven from several stakeholders’ perspectives—including governmental monitoring, hospital administrations, clinical specialty organisations and the care givers. However, exactly how healthcare quality should be assessed remains a difficult task. A particular challenge is the quest for defining surgical quality metrics. Some outcome metrics used in the past, such as in-hospital mortality or length of hospital stay after surgery, may not reflect the quality of care per se, especially when...

Introduction

‘Hybrid’ interventions in which some intervention components are fixed across sites and others are flexible (locally created) are thought to allow for adaptation to the local context while maintaining fidelity. However, there is little evidence regarding the challenges and facilitators of implementing hybrid interventions. This paper reports on a process evaluation of a patient safety hybrid intervention called Your Care Needs You (YCNY). YCNY was tested in the Partners at Care Transitions (PACT) randomised controlled trial and aimed to enhance older patients and their families’ involvement in their care in order to achieve safer transitions from hospital to home.

Methods

The process evaluation took place across eight intervention wards taking part in the PACT trial. 23 interviews and 37 informal conversations were conducted with National Health Service (NHS) staff. Patients (n=19) were interviewed twice, once in hospital and once after discharge. Interviews with staff and patients concerned the delivery and experiences of YCNY. Ethnographic observations (n=81 hours) of relevant activities (eg, multidisciplinary team meetings, handovers, etc) were undertaken.

Results

The main finding relates to how staff understood and engaged with YCNY, which then had a major influence on its implementation. While staff broadly valued the aims of YCNY, staff from seven out of the eight wards taking part in the process evaluation enacted YCNY in a mostly task-based manner. YCNY implementation often became a hurried activity which concentrated on delivering fixed intervention components rather than a catalyst for culture change around patient involvement. Factors such as understaffing, constraints on staff time and the COVID-19 pandemic contributed towards a ‘taskification’ of intervention delivery, which meant staff often did not have capacity to creatively devise flexible intervention components. However, one ward with a sense of distributed ownership of YCNY had considerable success implementing flexible components.

Discussion

Hybrid interventions may allow aspects of an intervention to be adapted to the local context. However, the current constrained and pressured environment of the NHS left staff with little ability to creatively engage with devising flexible intervention components, despite recognising the need for and being motivated to deliver the intervention.

Background

Search engines often serve as a primary resource for patients to obtain drug information. However, the search engine market is rapidly changing due to the introduction of artificial intelligence (AI)-powered chatbots. The consequences for medication safety when patients interact with chatbots remain largely unexplored.

Objective

To explore the quality and potential safety concerns of answers provided by an AI-powered chatbot integrated within a search engine.

Methodology

Bing copilot was queried on 10 frequently asked patient questions regarding the 50 most prescribed drugs in the US outpatient market. Patient questions covered drug indications, mechanisms of action, instructions for use, adverse drug reactions and contraindications. Readability of chatbot answers was assessed using the Flesch Reading Ease Score. Completeness and accuracy were evaluated based on corresponding patient drug information in the pharmaceutical encyclopaedia drugs.com. On a preselected subset of inaccurate chatbot answers, healthcare professionals evaluated likelihood and extent of possible harm if patients follow the chatbot’s given recommendations.

Results

Of 500 generated chatbot answers, overall readability implied that responses were difficult to read according to the Flesch Reading Ease Score. Overall median completeness and accuracy of chatbot answers were 100.0% (IQR 50.0–100.0%) and 100.0% (IQR 88.1–100.0%), respectively. Of the subset of 20 chatbot answers, experts found 66% (95% CI 50% to 85%) to be potentially harmful. 42% (95% CI 25% to 60%) of these 20 chatbot answers were found to potentially cause moderate to mild harm, and 22% (95% CI 10% to 40%) to cause severe harm or even death if patients follow the chatbot’s advice.

Conclusions

AI-powered chatbots are capable of providing overall complete and accurate patient drug information. Yet, experts deemed a considerable number of answers incorrect or potentially harmful. Furthermore, complexity of chatbot answers may limit patient understanding. Hence, healthcare professionals should be cautious in recommending AI-powered search engines until more precise and reliable alternatives are available.

Background

The raison d’etre of healthcare profession regulators across the globe is to protect patients and the public from the risk of harm. In cases of serious misconduct, remediation is deemed to be an important factor when considering the risk of harm from a practitioner under investigation. Yet, we know very little about how regulators account for remediation in their decision-making, and whether it is consistent with the aim of risk reduction. This paper explores the role of remediation in decision-making in cases of serious misconduct before UK healthcare regulators.

Methods

We conducted interviews with 21 participants from across eight of the nine UK healthcare profession regulators, covering a range of roles in the decision-making process in misconduct cases. Interviews were conducted remotely by video call and digitally transcribed. Data were analysed using the framework analysis method. The initial framework was developed from existing literature and guidance documents from the regulators, and was subsequently refined through the various rounds of coding.

Results

Remediation influenced decision-making in three ways: (1) Some types of misconduct were deemed more inherently remediable than others. In cases involving dishonesty or sexual misconduct, remediation was less likely to serve as a mitigating factor. (2) Decision-makers often view remediation as a proxy indicator of practitioner insight. (3) Whether a practitioner had demonstrated their commitment to change through undergoing remediation was more likely to feed into decision-making at the point where current impairment was under consideration.

Conclusions

Remediation plays a key role in decision-makers’ judgements in cases of misconduct, particularly when these cases relate to clinical misconduct. In such cases, remediation informs judgements on the levels of practitioner insight and the risk of such misconduct being repeated. Our results suggest a need to develop remediation interventions that are explicitly geared towards the regulatory function of developing practitioner insight. Regulators should also consider the structure of their fitness to practise processes and whether there are appropriate opportunities for judgements on remediation to feed into decisions and to facilitate balanced and proportionate outcomes.

Introduction

Quality improvement (QI) efforts are critical to promoting health equity and mitigating disparities in healthcare outcomes. Equity-focused QI (EF-QI) interventions address the unique needs of equity-deserving groups and the root causes of disparities. This scoping review aims to identify themes from EF-QI interventions that improve the health of equity-deserving groups, to serve as a resource for researchers embarking on QI.

Methods

In adherence with Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines, several healthcare and medical databases were systematically searched from inception to December 2022. Primary studies that report results from EF-QI interventions in healthcare were included. Reviewers conducted screening and data extraction using Covidence. Inductive thematic analysis using NVivo identified key barriers to inform future EF-QI interventions.

Results

Of 5,330 titles and abstracts screened, 36 articles were eligible for inclusion. They reported on EF-QI interventions across eight medical disciplines: primary care, obstetrics, psychiatry, paediatrics, oncology, cardiology, neurology and respirology. The most common focus was racialised communities (15/36; 42%). Barriers to EF-QI interventions included those at the provider level (training and supervision, time constraints) and institution level (funding and partnerships, infrastructure). The last theme critical to EF-QI interventions is sustainability. Only six (17%) interventions actively involved patient partners.

Discussion

EF-QI interventions can be an effective tool for promoting health equity, but face numerous barriers to success. It is unclear whether the demonstrated barriers are intrinsic to the equity focus of the projects or can be generalised to all QI work. Researchers embarking on EF-QI work should engage patients, in addition to hospital and clinic leadership in the design process to secure funding and institutional support, improving sustainability. To the best of our knowledge, no review has synthesised the results of EF-QI interventions in healthcare. Further studies of EF-QI champions are required to better understand the barriers and how to overcome them.

Generative artificial intelligence (AI) technologies have the potential to revolutionise healthcare delivery but require classification and monitoring of patient safety risks. To address this need, we developed and evaluated a preliminary classification system for categorising generative AI patient safety errors. Our classification system is organised around two AI system stages (input and output) with specific error types by stage. We applied our classification system to two generative AI applications to assess its effectiveness in categorising safety issues: patient-facing conversational large language models (LLMs) and an ambient digital scribe (ADS) system for clinical documentation. In the LLM analysis, we identified 45 errors across 27 patient medical queries, with omission being the most common (42% of errors). Of the identified errors, 50% were categorised as low clinical significance, 25% as moderate clinical significance and 25% as high clinical significance. Similarly, in the ADS simulation, we identified 66 errors across 11 patient visits, with omission being the most common (83% of errors). Of the identified errors, 55% were categorised as low clinical significance and 45% were categorised as moderate clinical significance. These findings demonstrate the classification system’s utility in categorising output errors from two different AI healthcare applications, providing a starting point for developing a robust process to better understand AI-enabled errors.

The healthcare delivered in high-income countries is riddled with defects in value. One in 10 patients experiences harm when receiving medical care, while nearly 13% of health expenditures are spent managing that harm.1 Half of patients with chronic disease are not on recommended therapy and suffer avoidable hospitalisations and ED visits, all while healthcare costs continue to increase as a percentage of GDP.2 3

Policymakers, health plans and health systems have responded to these challenges by working to improve value. While these efforts continue to mature, physicians are running up against the efficiency-thoroughness trade-off: to complete an increasing number of tasks in service of hitting quality metrics across their entire attributed population, they must decrease the time spent caring for each individual patient or increase the total amount of time they spend working. This paradox, however, is itself a product of how our...

Healthcare systems are currently buckling under the pressure of trying to manage the increasing demand for services. Nowhere is this pressure more acute than in intensive care units (ICUs). Technological developments, an ageing population, increased comorbidities and societal expectations about healthcare delivery and services have all driven demand for critical care resources to exceed capacity.1 ICUs amalgamate all medical and surgical specialties and support services to provide the best care for the most vulnerable and sickest hospital patients; they have been referred to as the ‘heart of the hospital’.2 Because of their pivotal role in providing complex care to different patient cohorts, ICUs require a flexible, nimble and adaptable workforce because when demand for ICU increases, the need for staff surges to meet this demand.3 Responding to resource challenges, increasing bed demands and the need for skilled and experienced staff requires significant adaptability...

In this issue of BMJ Quality & Safety, Hampton and colleagues report a process evaluation of an intervention trial intended to encourage older patients’ involvement in their hospital care.1

The logic of the intervention, Your Care Needs You (YCNY), was that more patient involvement in aspects of care in hospital will carry over to home after discharge, preventing avoidable repeat admissions. YCNY was described as a ‘hybrid’ intervention. Ward-level staff were obliged to deliver ‘fixed’ components—a booklet, and advice sheet and a video. But they were also invited to design and deliver ‘flexible’ components, that is, any other components that the ward team thought would also encourage patients to take part in the selected aspects of their care (some examples were offered by the investigators). One of their eight wards went all in, embracing the challenge of designing flexible components. But the others chose differently, keeping with...

The last 5 years have seen a rapid growth in research applying artificial intelligence or machine learning to improve the quality and safety of healthcare. This coincides with the release of web interfaces (such as ChatGPT from OpenAI and Copilot from Microsoft) that have enabled the general public (including health professionals and researchers) to easily access the latest generation of large language models (LLMs).

LLMs have fundamentally changed how machine learning is used across domains. Unlike previous generation systems that required careful data curation for specific tasks before training, modern LLMs work well with just a few examples or a simple problem description. This progress is mainly due to training on large volumes of web data that allows them to develop an ‘understanding’ of both language and general knowledge which they can then apply to a wide range of tasks.1

To fully comprehend the capabilities and associated...

Performance problems among healthcare professionals can have significant implications for patient safety. Estimates suggest approximately 6–12% of physicians experience performance issues,1 while about one in three healthcare professionals report encountering a poorly performing colleague within the past year.2 Performance problems can arise from individual-level causes including physical illness, substance use disorders, cognitive impairment, mood or personality disorders, and failure to acquire or maintain the knowledge and skills necessary to safely carry out their responsibilities.3 Furthermore, broader systemic issues, including excessive workloads, inadequate resources, lack of institutional support and poor workplace culture, can contribute to or exacerbate performance problems.4 The performance of healthcare professionals is generally evaluated against a set of standards or core competencies of a particular profession that commonly require health professionals to maintain the knowledge, procedural proficiencies, communication skills and professionalism to effectively care for patients. Deficiencies in any...

Background

Healthcare systems are operating under substantial pressures. Clinicians and managers are constantly having to make adaptations, which are typically improvised, highly variable and not coordinated across teams. This study aimed to identify and describe the types of everyday pressures in intensive care and the adaptive strategies staff use to respond, with the longer-term aim of developing practical and coordinated strategies for managing under pressure.

Methods

We conducted qualitative semi-structured interviews with 20 senior multidisciplinary healthcare professionals from intensive care units (ICUs) in 4 major hospitals in the UK. The interviews explored the everyday pressures faced by intensive care staff and the strategies they use to adapt. A thematic template analysis approach was used to analyse the data based on our previously empirically developed taxonomy of pressures and strategies.

Results

The principal source of pressure described was a shortage of staff with the necessary skills and experience to care for the increased numbers and complexity of patients which, in turn, increased staff workload and reduced patient flow. Strategies were categorised into anticipatory (in advance of anticipated pressures) and on the day. The dynamic and unpredictable demands on ICUs meant that strategies were mostly deployed on the day, most commonly by flexing staff, prioritisation of patients and tasks and increasing modes of communication and support.

Conclusions

ICU staff use a wide variety of adaptive strategies at times of pressure to minimise risk and maintain a reasonable standard of care for patients. These findings provide the foundation for a portfolio of strategies, which can be flexibly employed when under pressure. There is considerable potential for training clinical leaders and teams in the effective use of adaptive strategies.