Etienne Minvielle

Barriers to staff adoption of a surgical safety checklist

Objective Implementation of a surgical checklist depends on many organisational factors and on socio-cultural patterns. The objective of this study was to identify barriers to effective implementation of a surgical checklist and to develop a best use strategy. Setting 18 cancer centres in France. Design The authors first assessed use compliance and completeness rates of the surgical checklist on a random sample of 80 surgical procedures performed under general or loco-regional anaesthesia in each of the 18 centres. They then developed a typology of the organisational and cultural barriers to effective checklist implementation and defined each barriers contents using data from collective and semi-structured individual interviews of key staff, the results of an email questionnaire sent to the 18 centres, and direct observations over 20 h in two centres. Results The study consisted of 1440 surgical procedures, 1299 checklists, and 28 578 items. The mean compliance rate was 90.2% (0, 100). The mean completion rate was 61% (0, 84). 11 barriers to effective checklist implementation were identified. Their incidence varied widely across centres. The main barriers were duplication of items within existing checklists (16/18 centres), poor communication between surgeon and anaesthetist (10/18), time spent completing the checklist for no perceived benefit, and lack of understanding and timing of item checks (9/18), ambiguity (8/18), unaccounted risks (7/18) and a time-honoured hierarchy (6/18). Conclusions Several of the barriers to the successful implementation of the surgical checklist depended on organisational and cultural factors within each centre. The authors propose a strategy for change for checklist design, use and assessment, which could be used to construct a feedback loop for local team organisation and national initiatives.

Relationship between longitudinal continuity of primary care and likelihood of death: analysis of national insurance data.

Background Continuity of care (COC) is a widely accepted core principle of primary care and has been associated with patient satisfaction, healthcare utilization and mortality in many, albeit small, studies. Objective To assess the relationship between longitudinal continuity with a primary care physician (PCP) and likelihood of death in the French general population. Design Observational study based on reimbursement claims from the French national health insurance (NHI) database for salaried workers (2007–2010). Setting Primary care. Patients We extracted data on the number and pattern of visits made to a PCP and excluded all patients who did not visit a PCP at least twice within 6 months. We recorded age, gender, comorbidities, social status, and deaths. Main outcome measures The primary endpoint was death by all causes. We measured longitudinal continuity of care (COC) with a PCP twice a year between 2007 and 2010, using the COC index developed by Bice and Boxerman. We introduced the COC index as time-dependent variables in a survival analysis after adjustment for age, gender and stratifying on comorbidities and social status. Results A total of 325 742 patients were included in the analysis. The average COC index ranged from 0.74 (SD: 0.35) to 0.76 (0.35) (where 1.0 is perfect continuity). Likelihood of death was lower in patients with higher continuity (hazard ratio for an increase in 0.1 of continuity, adjusted for age, sex, and stratified on comorbidities and social status: 0.96 [0.95–0.96]). Conclusion Higher longitudinal continuity was associated with a reduced likelihood of death.

Assessing organizational performance in intensive care units: A French experience

OBJECTIVE The objective of the study was to assess and to explain variation of organizational performance in intensive care units (ICUs). DESIGN This was a prospective multicenter study. SETTING The study involved 26 ICUs located in the Paris area, France, participating in a regional database. METHODS Data were collected through answers of 1000 ICU personnel to the Culture, Organization, and Management in Intensive Care questionnaire and from the database. Organizational performance was assessed through a composite score related to 5 dimensions: coordination and adaptation to uncertainty, communication, conflict management, organizational change, and organizational learning, Skills developed in relationship with patients and their families. Statistical comparisons between ICUs were performed by analysis of variance with a Scheffé pairwise procedure. A multilevel regression model was used to analyze both individual and structural variables explaining differences of ICUs organizational performance. RESULTS The organizational performance score differed among ICUs. Some cultural values were negatively correlated with a high level of organizational performance, suggesting improvement potential. Several individual and structural factors were also related to the quality of ICU organization, including absence of burnout, older staff, satisfaction to work, and high workload (P < .02 for each). CONCLUSIONS A benchmarking approach can be used by ICU managers to assess the organizational performance of their ICU based on a validated questionnaire. Differences are mainly explained by cultural values and individual well-being factors, introducing new requirements for managing human resources in ICUs.

Managing customization in health care: A framework derived from the services sector literature

Organizations that provide health services are increasingly in need of systems and approaches that will enable them to be more responsive to the needs and wishes of their clients. Two recent trends, namely, patient-centered care (PCC) and personalized medicine, are first steps in the customization of care. PCC shifts the focus away from the disease to the patient. Personalized medicine, which relies heavily on genetics, promises significant improvements in the quality of healthcare through the development of tailored and targeted drugs. We need to understand how these two trends can be related to customization in healthcare delivery and, because customization often entails extra costs, to define new business models. This article analyze how customization of the care process can be developed and managed in healthcare. Drawing on relevant literature from various services sectors, we have developed a framework for the implementation of customization by the hospital managers and caregivers involved in care pathways.

Constructing a composite quality score for the care of acute myocardial infarction patients at discharge: impact on hospital ranking.

ObjectiveTo determine the impact on hospital ranking of different aggregation methods when creating a composite score from a set of quality indicators relating to a single clinical condition. DesignThe analysis was based on 14966 medical records taken from all French hospitals that treated over 30 patients with acute myocardial infarction in 2008 (n=275). Five quality indicators measuring the quality of care delivered to patients with acute myocardial infarction at hospital discharge were aggregated by 5 methods issued from a variety of activity sectors (indicator average, all-or-none, budget allocation process, benefit of the doubt, and unobserved component model). Main Outcome MeasuresEach aggregation method was used to rank hospitals into 3 categories depending on the position of the 95% confidence interval of the composite score relative to the overall mean. Variations in rank according to method were estimated using weighted &kgr; coefficients. ResultsAgreement between methods ranged from poor (&kgr;=0.20) to almost perfect (&kgr;=0.84). A change of method led to a change in rank for 71% (196 of 275) of hospitals. Only 14 of 121 hospitals which were ranked top and 20 of 118 which were ranked bottom, by at least 1 of the 5 methods, held their rank on a switch to the 4 other methods. ConclusionHospital ranking varied widely according to 5 aggregation methods. If one method has to be chosen, for instance for reporting to governments, regulatory agencies, payers, health care professionals, and the public, it is necessary to provide its rationale and characteristics, and information on score uncertainty.

How to limit the burden of data collection for Quality Indicators based on medical records? The COMPAQH experience

BackgroundOur objective was to limit the burden of data collection for Quality Indicators (QIs) based on medical records.MethodsThe study was supervised by the COMPAQH project. Four QIs based on medical records were tested: medical record conformity; traceability of pain assessment; screening for nutritional disorders; time elapsed before sending copy of discharge letter to the general practitioner. Data were collected by 6 Clinical Research Assistants (CRAs) in a panel of 36 volunteer hospitals and analyzed by COMPAQH. To limit the burden of data collection, we used the same sample of medical records for all 4 QIs, limited sample size to 80 medical records, and built a composite score of only 10 items to assess medical record completeness. We assessed QI feasibility by completing a grid of 19 potential problems and evaluating time spent. We assessed reliability (κ coefficient) as well as internal consistency (Cronbach α coefficient) in an inter-observer study, and discriminatory power by analysing QI variability among hospitals.ResultsOverall, 23 115 data items were collected for the 4 QIs and analyzed. The average time spent on data collection was 8.5 days per hospital. The most common feasibility problem was misunderstanding of the item by hospital staff. QI reliability was good (κ: 0.59–0.97 according to QI). The hospitals differed widely in their ability to meet the quality criteria (mean value: 19–85%).ConclusionThese 4 QIs based on medical records can be used to compare the quality of record keeping among hospitals while limiting the burden of data collection, and can therefore be used for benchmarking purposes. The French National Health Directorate has included them in the new 2009 version of the accreditation procedure for healthcare organizations.

Développement d’indicateurs de qualité au sein des établissements de santé : le projet COMPAQH

Position du probleme Le projet COMPAQH, coordonne par l’Institut national de la sante et de recherche medicale, a pour objectif de selectionner une batterie d’indicateurs de la qualite de la prise en charge du patient (IQ) par les Etablissements de Sante (ES) afin de les tester et de les valider en 2004-2005, au sein d’un panel de 36 ES volontaires, de comparer anonymement les ES et d’en etudier les implications manageriales. Methodes En 2003, la selection des indicateurs a ete realisee en quatre etapes : (1) Definition d’objectifs prioritaires (OP) de l’amelioration de la qualite. Elle a ete elaboree par les promoteurs du projet (Direction de l’hospitalisation et de l’organisation des soins, Agence nationale d’accreditation et d’evaluation en sante et Federations hospitalieres) et les ES participants selon cinq criteres : importance du theme (notamment coherence avec les priorites nationales de sante publique), variabilite inter-etablissements, mesures existantes, marge d’amelioration, coherence avec le manuel d’accreditation. (2) Definition de 81 IQ illustrant ces OP a partir d’une analyse de la litterature ; chaque IQ est decrit par un « cahier des charges » (justification de l’interet, modalites de construction, modes de recueil de donnees). (3) Evaluation des 81 IQ selon quatre criteres: importance du phenomene etudie, qualites metrologiques, faisabilite et coherence avec les demarches existantes. (4) Selection definitive des IQ a tester selon une methode Delphi. Resultats (1) Huit OP ont ete definis : lutter contre la douleur, assurer la continuite de la prise en charge, lutter contre les troubles nutritionnels, lutter contre le risque iatrogene (dont les infections nosocomiales), ameliorer la satisfaction du patient, respecter les bonnes pratiques cliniques, accroitre la motivation, la responsabilisation et l’evaluation des competences des professionnels, garantir l’accessibilite. (2) 42 IQ ont ete selectionnes : 6 IQ communs a tous les ES et 7 a 18 IQ specifiques selon les secteurs d’activite des ES participants. Conclusion Les IQ selectionnes associent majoritairement des mesures de processus a des mesures de resultats. Le principal critere de selection retenu par les ES est la faisabilite du recueil des donnees. L’utilisation des IQ se concoit selon trois objectifs : amelioration interne, diffusion publique, regulation des financements hospitaliers.

Method for developing national quality indicators based on manual data extraction from medical records

Developing quality indicators (QI) for national purposes (eg, public disclosure, paying-for-performance) highlights the need to find accessible and reliable data sources for collecting standardised data. The most accurate and reliable data source for collecting clinical and organisational information still remains the medical record. Data collection from electronic medical records (EMR) would be far less burdensome than from paper medical records (PMR). However, the development of EMRs is costly and has suffered from low rates of adoption and barriers of usability even in developed countries. Currently, methods for producing national QIs based on the medical record rely on manual extraction from PMRs. We propose and illustrate such a method. These QIs display feasibility, reliability and discriminative power, and can be used to compare hospitals. They have been implemented nationwide in France since 2006. The method used to develop these QIs could be adapted for use in large-scale programmes of hospital regulation in other, including developing, countries.

Factors associated with the length of stay of patients discharged from emergency department in France.

Objectives The length of stay in the emergency department (ED) has been proposed as an indicator of performance in many countries. We conducted a survey of length of stay in two large areas in France and tested the hypothesis that patient and ED-related variables may influence it. Patients and methods During 2007, we examined lengths of stay in ambulatory patients, that is, excluding admitted patients. The following variables were considered: (a) at the patient level, age, sex, the day and month of the visit, and the French clinical classification of emergency patients (CCEP) class; (b) at the ED level, annual ED total number of visits, mean age, the proportions of patients less than 15 and more than 75 years, and the proportions of admitted and clinically stable patients with CCEP class 1 and 2. A multilevel hierarchical analysis was carried out. Results We analyzed 988 591 visits in 53 EDs. The ED-specific median length of stay was 98 (IQR: 62–137) min and the ED-specific median proportion of patients with length of stay of more than 4 h was 15 (5–24) %. There was a strong correlation between the ED-specific median length of stay and the ED-specific proportion of patients with a length of stay of more than 4 h (R=0.96, P<0.001). Using a multilevel analysis, only three variables were associated significantly with the length of stay: the age and the CCEP class of the patient, and the ED census. Conclusion We observed that the length of stay in the ED needs to be stratified by case mix and the total number of visits of the ED.

Development and feasibility of a set of quality indicators relative to the timeliness and organisation of care for new breast cancer patients undergoing surgery

BackgroundBecause breast cancer is a major public health issue, it is particularly important to measure the quality of the care provided to patients. Survival rates are affected by the timeliness of care, and waiting times constitute key quality criteria. The aim of this study was to develop and validate a set of quality indicators (QIs) relative to the timeliness and organisation of care in new patients with infiltrating, non-inflammatory and metastasis-free breast cancer undergoing surgery. The ultimate aim was to use these QIs to compare hospitals.MethodsThe method of QI construction and testing was developed by COMPAQ-HPST. We first derived a set of 8 QIs from consensus guidelines with the aid of experts and professional associations and then tested their metrological properties in a panel of 60 volunteer hospitals. We assessed feasibility using a grid exploring 5 dimensions, discriminatory power using the Gini coefficient as a measure of dispersion, and inter-observer reliability using the Kappa coefficient.ResultsOverall, 3728 records were included in the analyses. All 8 QIs showed acceptable feasibility (but one QI was subject to misinterpretation), fairly strong agreement between observers (Kappa = 0.66), and wide variations in implementation among hospitals (Gini coefficient < 0.45 except for QI 6 (patient information)). They are thus suitable for use to compare hospitals and measure quality improvement.ConclusionsOf the 8 QIs, 3 are ready for nationwide implementation (time to surgery, time to postoperative multidisciplinary team meeting (MDTM), conformity of MDTM). Four are suitable for use only in hospitals offering surgery with on-site postoperative treatment (waiting time to first appointment after surgery, patient information, time to first postoperative treatment, and traceability of information relating to prognosis). Currently, in the French healthcare system, a patient receives cancer care from different institutions whose databases cannot as yet be easily merged. Nationwide implementation of QIs covering the entire care pathway will thus be a challenge.