Background

Voluntary assisted dying (VAD) in Victoria, Australia, is governed by a stringent legislative framework, designed and enforced by the state, as well as other forms of regulation. However, there remains limited understanding about how these various forms of regulation operate at the frontline or how clinicians themselves can influence regulation.

Objectives

This article explores how clinicians working at the frontline (clinical coalface) may influence the regulation of VAD in Victoria, and how this contributes to the safe and effective delivery of VAD.

Methods

Reflexive thematic analysis of 30 semistructured interviews with 37 ‘regulators’ (defined as those capable of steering and guiding behaviour with respect to VAD).

Results

Data analysis resulted in the generation of three main themes: (1) coalface regulation extends regulations at the clinical level, ensuring adherence to laws while developing new standards and systems for safe and effective practice; (2) coalface regulation guides day-to-day VAD practice; and (3) coalface regulation plays a critical role in quality monitoring and improvement.

Conclusions

Clinicians play a significant role in VAD regulation in Victoria and fulfil what we define as a ‘coalface regulator’ role. These coalface regulators are influential in ensuring the safe and effective delivery of VAD. Understanding how coalface regulation intersects with other forms of VAD regulation and how this regulatory influence can be harnessed is critical for optimising VAD regulation, safety and improving service delivery at a local and system level.

Objective

Quality improvement (QI) practices and scholarship are increasingly concerned with environmental sustainability given the negative health outcomes caused by the ecological crisis, as well as the environmental impacts of healthcare delivery itself. A core component of QI activities is measuring change. How sustainability metrics have been used in QI is unclear. We conducted a scoping review of metrics used in published sustainability-focused QI initiatives.

Data sources

MEDLINE, EMBASE, CINAHL and Scopus from 2000 to 2023.

Eligibility criteria

Published healthcare QI initiatives intended to address environmental sustainability with at least one quantitative sustainability metric.

Data analysis

Publication, study, measurement and QI intervention characteristics were charted from included studies. Data items were synthesised and presented narratively as well as quantitatively.

Results

We screened 6294 studies and included 90 full-text publications. The studies were published from 2000 to 2023, with the majority (61%, 55/90) published since 2020. Publications originated from a wide range of clinical disciplines with most QI projects situated in the inpatient setting (78%, 70/90). Environmental sustainability metrics were subcategorised into activity data and environmental impact indicators. Some papers included more than one category of activity data, with the most common being cost (88%, 79/90), hospital waste (52%, 47/90), anaesthetic gases (49%, 44/90), disposable use (24%, 22/90) and distance travelled (14%, 13/90). Fewer publications included environmental impact indicators, with global warming potential dominating this category (53%, 48/90).

Discussion

There is a need to align QI efforts with environmental sustainability. However, there is limited guidance specific to healthcare QI on how to measure environmental impacts of these efforts. This review illuminates that sustainability-focused QI efforts to date have used a relatively narrow set of sustainability metrics. QI scholars and practitioners can benefit from further education, measurement frameworks and guidelines to effectively incorporate environmental sustainability metrics into QI efforts.

Objectives

With the growing adoption of virtual consultations in primary care, the need for tailored metrics to evaluate their safety became increasingly urgent. This systematic review seeks to identify and review existing safety measures that could be used for safety evaluation of virtual consultations in primary care.

Methods

This has been conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and followed a published protocol. A systematic literature search was performed in Ovid MEDLINE/PubMed, Embase and Cochrane Library databases from 2014 to 2024. Studies comparing virtual consultations with face-to-face consultations in the primary care setting were included. An inductive thematic analysis was performed to systematically extract and group the safety measures into overarching themes, with a narrative synthesis to summarise the results.

Results

A total of 47 studies (31 experimental and 16 observational studies) were included (n=2 223 697 patients). All studies assessed the safety of virtual versus face-to-face consultations via one or both of the following domains: (1) factors that influence the safety of virtual consultations and (2) tangible outcomes of virtual care safety. The former were categorised into provider-related, patient-related and system-related factors. Tangible outcomes were evident through three subthemes—adverse events, health outcomes and patient perception of safety.

Conclusions

This review provides a systematic synthesis of measures for the safety evaluation of virtual consultations. Further research into patient and physician perspectives is needed to identify aspects and indicators not captured in this study, followed by a consensus study to finalise safety metrics. Ultimately, having a robust methodology for safety evaluation of virtual consultations in place will enable safety monitoring, root cause analyses and safety improvement.

PROSPERO registration number

PROSPERO CRD42023464878.

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