 |
Medication Safety Officers Society 3903 Members Strong A society of healthcare professionals dedicated to improving medication safety in healthcare organizations |
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...
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.
MethodsWe 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.
ResultsEffective 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.
ConclusionsResults 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.
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.
MethodsBetween 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.
ResultsA 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.
ConclusionsImplementing 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.
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.
Results22 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.
ConclusionsUnderstanding 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 numberCRD42022290060.
Urinary tract infection (UTI) is the most diagnosed infection in older people living in care homes.
ObjectiveTo 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.
MethodsA 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.
Results56 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.
ConclusionsCare 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.
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 sourcesPubMed.
Eligibility criteriaPrimary 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 analysisPrimary 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.
ResultsSixteen 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.
DiscussionHistorically 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...
