Carola Orrego

Organizational culture: an important context for addressing and improving hospital to community patient discharge

Background:Organizational culture is seen as having a growing impact on quality and safety of health care, but its impact on hospital to community patient discharge is relatively unknown. Objectives:To explore aspects of organizational culture to develop a deeper understanding of the discharge process. Research Design:A qualitative study of stakeholders in the discharge process. Grounded Theory was used to analyze the data. Subjects:In 5 European Union countries, 192 individual and 25 focus group interviews were conducted with patients and relatives, hospital physicians, hospital nurses, general practitioners, and community nurses. Results:Three themes emerged representing aspects of organizational culture: a fragmented hospital to primary care interface, undervaluing administrative tasks relative to clinical tasks in the discharge process, and lack of reflection on the discharge process or process improvement. Nine categories were identified: inward focus of hospital care providers, lack of awareness to needs, skills, and work patterns of the professional counterpart, lack of a collaborative attitude, relationship between hospital and primary care providers, providing care in a “here and now” situation, administrative work considered to be burdensome, negative attitude toward feedback, handovers at discharge ruled by habits, and appreciating and integrating new practices. Conclusions:On the basis of the data, we hypothesize that the extent to which hospital care providers value handovers and the outreach to community care providers is critical to effective hospital discharge. Community care providers often are insufficiently informed about patient outcomes. Ongoing challenges with patient discharge often remain unspoken with opportunities for improvement overlooked. Interventions that address organizational culture as a key factor in discharge improvement efforts are needed.

Improving patient discharge and reducing hospital readmissions by using Intervention Mapping

BackgroundThere is a growing impetus to reorganize the hospital discharge process to reduce avoidable readmissions and costs. The aim of this study was to provide insight into hospital discharge problems and underlying causes, and to give an overview of solutions that guide providers and policy-makers in improving hospital discharge.MethodsThe Intervention Mapping framework was used. First, a problem analysis studying the scale, causes, and consequences of ineffective hospital discharge was carried out. The analysis was based on primary data from 26 focus group interviews and 321 individual interviews with patients and relatives, and involved hospital and community care providers. Second, improvements in terms of intervention outcomes, performance objectives and change objectives were specified. Third, 220 experts were consulted and a systematic review of effective discharge interventions was carried out to select theory-based methods and practical strategies required to achieve change and better performance.ResultsIneffective discharge is related to factors at the level of the individual care provider, the patient, the relationship between providers, and the organisational and technical support for care providers. Providers can reduce hospital readmission rates and adverse events by focusing on high-quality discharge information, well-coordinated care, and direct and timely communication with their counterpart colleagues. Patients, or their carers, should participate in the discharge process and be well aware of their health status and treatment. Assessment by hospital care providers whether discharge information is accurate and understood by patients and their community counterparts, are important examples of overcoming identified barriers to effective discharge. Discharge templates, medication reconciliation, a liaison nurse or pharmacist, regular site visits and teach-back are identified as effective and promising strategies to achieve the desired behavioural and environmental change.ConclusionsThis study provides a comprehensive guiding framework for providers and policy-makers to improve patient handover from hospital to primary care.

“It's like two worlds apart”: an analysis of vulnerable patient handover practices at discharge from hospital

Background Handover practices at hospital discharge are relatively under-researched, particularly as regards the specific risks and additional requirements for handovers involving vulnerable patients with limited language, cognitive and social resources. Objective To explore handover practices at discharge and to focus on the patients’ role in handovers and on the potential additional risks for vulnerable patients. Methods We conducted qualitative interviews with patients, hospital professionals and primary care professionals in two hospitals and their associated primary care centres in Catalonia, Spain. Results We identified handover practices at discharge that potentially put patients at risk. Patients did not feel empowered in the handover but were expected to transfer information between care providers. Professionals identified lack of medication reconciliation at discharge, loss of discharge information, and absence of plans for follow-up care in the community as quality and safety problems for discharge handovers. These occurred for all patients, but appeared to be more frequent and have a greater negative effect in patients with limited language comprehension and/or lack of family and social support systems. Conclusions Discharge handovers are often haphazard. Healthcare professionals do not consider current handover practices safe, with patients expected to transfer information without being empowered to understand and act on it. This can lead to misinformation, omission or duplication of tests or interventions and, potentially, patient harm. Vulnerable patients may be at greater risk given their limited language, cognitive and social resources. Patient safety at discharge could benefit from strategies to enhance patient education and promote empowerment.

The key actor: a qualitative study of patient participation in the handover process in Europe

Background Patient safety experts have postulated that increasing patient participation in communications during patient handovers will improve the quality of patient transitions, and that this may reduce hospital readmissions. Choosing strategies that enhance patient safety through improved handovers requires better understanding of patient experiences and preferences for participation. Objective The aim of this paper is to explore the patients’ experiences and perspectives related to the handovers between their primary care providers and the inpatient hospital. Methods A qualitative secondary analysis was performed, based on individual and focus group patient interviews with 90 patients in five European countries. Results The analysis revealed three themes: patient positioning in the handover process; prerequisites for patient participation and patient preferences for the handover process. Patients’ participation ranged from being the key actor, to sharing the responsibility with healthcare professional(s), to being passive participants. For active participation patients required both personal and social resources as well as prerequisites such as information and respect. Some patients preferred to be the key actor in charge; others preferred their healthcare professionals to be the key actors in the handover. Conclusions Patients’ participation is related to the healthcare system, the activity of healthcare professionals’ and patients’ capacity for participation. Patients prefer a handover process where the responsibility is clear and unambiguous. Healthcare organisations need a clear and well-considered system of responsibility for handover processes, that takes into account the individual patients need of clarity, and support in relation to his/hers own recourses.

Los sistemas de registro y notificación de efectos adversos y de incidentes: una estrategia para aprender de los errores

The need to find strategies of error prevention and promotion of patient safety has stimulated countries to develop models that improve knowledge of adverse events. One of the tools used are reporting systems for gathering information about errors. To review existing reporting systems, to describe the models developed by the countries with the longest tradition in designing strategies for the promotion of patient safety and prevention of adverse events and to determine the factors required for the development of future reporting systems. Adverse event reporting systems were created in nonmedical fields, with the aim of collecting information relating to near-misses (without harm) or accidents (with harm). This information was used to establish a profile of the most frequent problems in an organization and to understand the factors that contribute to errors. There are different types of reporting systems. Nevertheless, independently of the reporting system used, their application and development benefits the organization since they generate opportunities for modeling events, monitoring, increasing awareness of safety problems and more efficient resource use. New strategies should be designed to increase health professionals’ commitment to reporting adverse events. Legal and organizational barriers that hamper their implementation should be analyzed.

Epidemiología de los eventos adversos hospitalarios en Catalunya: un primer paso para la mejora de la seguridad del paciente

It has been published that hospital adverse events are an important source of morbidity and mortality in different countries and settings. The aim of this study was to evaluate the frequency, magnitude, distribution and degree of preventability of adverse events in the Autonomous Community of Catalonia (Spain). We conducted a retrospective cohort study of 4,790 hospital discharges that were selected by simple random sampling after stratified multistage sampling in 15 hospitals in Catalonia. 38.25% of patients had positive risk criteria (screening phase). We identified 356 cases of adverse events, which represent a 7.4% (95%CI: 6.7% to 8.1%). Of these, 43.5% (155 cases) were considered preventable. This study confirms that adverse events in hospitals in Catalonia are frequent, and generate a significant impact on morbidity and mortality. As in other studies, corroborated that a high proportion of these adverse events are considered preventable. It was possible to identify priority areas to focus improvement efforts.

Derechos de los pacientes en los principales sistemas de acreditación hospitalaria

Resumen Objetivo Analizar como se abordan los derechos de los pacientes en los principales sistemas de acreditacion del mundo. Material y metodo Estudio de los principales sistemas de acreditacion hospitalaria existentes, empleando una metodologia cualitativa de analisis de textos. Los estandares de derechos de pacientes de los distintos sistemas de acreditacion son agrupados segun el tema que tratan. Se establecen 9 temas principales: Informacion al paciente, Intimidad, trato y apoyo emocional, Proteccion del paciente, Proteccion de la autonomia, Donacion de organos, Codigo de derechos del paciente, Expresion de quejas y reclamaciones, Etica de la organizacion y Nuevos derechos. Resultados No todos los sistemas de acreditacion estudiados incluyen un capitulo sobre derechos de los pacientes. A pesar de las diferencias observadas en la cobertura que los sistemas de acreditacion dan a los derechos de los pacientes, tanto por la profundidad de su analisis como por los aspectos concretos que cubren los estandares, todos los sistemas de acreditacion estudiados tratan este tema, aunque no sea en forma de un capitulo independiente. Conclusiones En la revision realizada se evidencia la creciente importancia del tema de los derechos de los pacientes en los sistemas de acreditacion.