Janet Anderson

Can incident reporting improve safety? Healthcare practitioners' views of the effectiveness of incident reporting

OBJECTIVEnRecent critiques of incident reporting suggest that its role in managing safety has been over emphasized. The objective of this study was to examine the perceived effectiveness of incident reporting in improving safety in mental health and acute hospital settings by asking staff about their perceptions and experiences.nnnDESIGNnQualitative research design using documentary analysis and semi-structured interviews.nnnSETTINGnTwo large teaching hospitals in London; one providing acute and the other mental healthcare.nnnPARTICIPANTSnSixty-two healthcare practitioners with experience of reporting and analysing incidents.nnnRESULTSnIncident reporting was perceived as having a positive effect on safety, not only by leading to changes in care processes but also by changing staff attitudes and knowledge. Staff discussed examples of both instrumental and conceptual uses of the knowledge generated by incident reports. There are difficulties in using incident reports to improve safety in healthcare at all stages of the incident reporting process. Differences in the risks encountered and the organizational systems developed in the two hospitals to review reported incidents could be linked to the differences we found in attitudes to incident reporting between the two hospitals.nnnCONCLUSIONnIncident reporting can be a powerful tool for developing and maintaining an awareness of risks in healthcare practice. Using incident reports to improve care is challenging and the study highlighted the complexities involved and the difficulties faced by staff in learning from incident data.

Review of simulation studies in anaesthesia journals, 2001–2010: mapping and content analysis

Despite widespread adoption of simulation-based training in medical education, there remains scepticism about its cost-effectiveness and long-term impact on patient outcomes. Medical simulation is well established in anaesthesia where it is considered an important educational tool. This review of key clinical anaesthesia literature is used as a case study of clinician uptake within a specialty and to investigate evidence for translational impact using both qualitative and quantitative data. We examined high-impact journal publications from 2001 to 2010 and extracted data covering authors, institutions, simulation modality, purposes of simulation, and various aspects of study design/methodology used. A total of 320 papers containing primary data were included. We found broad acceptance and uptake in anaesthesia with an increase in publications over the time period, mainly attributable to a steady increase in manikin studies. Studies using manikin technology (130/320; 41%) are distinguished as skills/performance studies (76; 58%) and studies focused on the use, testing, and validation of equipment (52; 40%). A total of 110 papers (34%) assessed the performance of technical and non-technical skills (68% and 32%, respectively). Growth in the use of structured checklists/validated tools to assess performance is mainly observed in the non-technical domain. Only 10% of these papers include follow-up data from the clinical environment. There is a lack of research examining performance transfer, sustainability, and direct patient outcomes and experiences. These publication patterns are instructive for those involved in medical educational and for other clinical specialties developing simulation.

Does the process map influence the outcome of quality improvement work? A comparison of a sequential flow diagram and a hierarchical task analysis diagram

BackgroundMany quality and safety improvement methods in healthcare rely on a complete and accurate map of the process. Process mapping in healthcare is often achieved using a sequential flow diagram, but there is little guidance available in the literature about the most effective type of process map to use. Moreover there is evidence that the organisation of information in an external representation affects reasoning and decision making. This exploratory study examined whether the type of process map - sequential or hierarchical - affects healthcare practitioners judgments.MethodsA sequential and a hierarchical process map of a community-based anti coagulation clinic were produced based on data obtained from interviews, talk-throughs, attendance at a training session and examination of protocols and policies. Clinic practitioners were asked to specify the parts of the process that they judged to contain quality and safety concerns. The process maps were then shown to them in counter-balanced order and they were asked to circle on the diagrams the parts of the process where they had the greatest quality and safety concerns. A structured interview was then conducted, in which they were asked about various aspects of the diagrams.ResultsQuality and safety concerns cited by practitioners differed depending on whether they were or were not looking at a process map, and whether they were looking at a sequential diagram or a hierarchical diagram. More concerns were identified using the hierarchical diagram compared with the sequential diagram and more concerns were identified in relation to clinical work than administrative work. Participants preference for the sequential or hierarchical diagram depended on the context in which they would be using it. The difficulties of determining the boundaries for the analysis and the granularity required were highlighted.ConclusionsThe results indicated that the layout of a process map does influence perceptions of quality and safety problems in a process. In quality improvement work it is important to carefully consider the type of process map to be used and to consider using more than one map to ensure that different aspects of the process are captured.

Assessing the validity of prospective hazard analysis methods: a comparison of two techniques

BackgroundProspective Hazard Analysis techniques such as Healthcare Failure Modes and Effects Analysis (HFMEA) and Structured What If Technique (SWIFT) have the potential to increase safety by identifying risks before an adverse event occurs. Published accounts of their application in healthcare have identified benefits, but the reliability of some methods has been found to be low. The aim of this study was to examine the validity of SWIFT and HFMEA by comparing their outputs in the process of risk assessment, and comparing the results with risks identified by retrospective methods.MethodsThe setting was a community-based anticoagulation clinic, in which risk assessment activities had been previously performed and were available. A SWIFT and an HFMEA workshop were conducted consecutively on the same day by experienced experts. Participants were a mixture of pharmacists, administrative staff and software developers. Both methods produced lists of risks scored according to the method’s procedure. Participants’ views about the value of the workshops were elicited with a questionnaire.ResultsSWIFT identified 61 risks and HFMEA identified 72 risks. For both methods less than half the hazards were identified by the other method. There was also little overlap between the results of the workshops and risks identified by prior root cause analysis, staff interviews or clinical governance board discussions. Participants’ feedback indicated that the workshops were viewed as useful.ConclusionsAlthough there was limited overlap, both methods raised important hazards. Scoping the problem area had a considerable influence on the outputs. The opportunity for teams to discuss their work from a risk perspective is valuable, but these methods cannot be relied upon in isolation to provide a comprehensive description. Multiple methods for identifying hazards should be used and data from different sources should be integrated to give a comprehensive view of risk in a system.

Simulation training for improving the quality of care for older people: an independent evaluation of an innovative programme for inter-professional education

Introduction This paper describes the evaluation of a 2-day simulation training programme for staff designed to improve teamwork and inpatient care and compassion in an older persons’ unit. Objective The programme was designed to improve inpatient care for older people by using mixed modality simulation exercises to enhance teamwork and empathetic and compassionate care. Methods Healthcare professionals took part in: (a) a 1-day human patient simulation course with six scenarios and (b) a 1-day ward-based simulation course involving five 1-h exercises with integrated debriefing. A mixed methods evaluation included observations of the programme, precourse and postcourse confidence rating scales and follow-up interviews with staff at 7–9u2005weeks post-training. Results Observations showed enjoyment of the course but some anxiety and apprehension about the simulation environment. Staff self-confidence improved after human patient simulation (t=9; df=56; p<0.001) and ward-based exercises (t=9.3; df=76; p<0.001). Thematic analysis of interview data showed learning in teamwork and patient care. Participants thought that simulation had been beneficial for team practices such as calling for help and verbalising concerns and for improved interaction with patients. Areas to address in future include widening participation across multi-disciplinary teams, enhancing post-training support and exploring further which aspects of the programme enhance compassion and care of older persons. Conclusions The study demonstrated that simulation is an effective method for encouraging dignified care and compassion for older persons by teaching team skills and empathetic and sensitive communication with patients and relatives.

Prospects for comparing European hospitals in terms of quality and safety: lessons from a comparative study in five countries

Purpose Being able to compare hospitals in terms of quality and safety between countries is important for a number of reasons. For example, the 2011 European Union directive on patients rights to cross-border health care places a requirement on all member states to provide patients with comparable information on health-care quality, so that they can make an informed choice. Here, we report on the feasibility of using common process and outcome indicators to compare hospitals for quality and safety in five countries (England, Portugal, The Netherlands, Sweden and Norway). Main Challenges Identified The cross-country comparison identified the following seven challenges with respect to comparing the quality of hospitals across Europe: different indicators are collected in each country; different definitions of the same indicators are used; different mandatory versus voluntary data collection requirements are in place; different types of organizations oversee data collection; different levels of aggregation of data exist (country, region and hospital); different levels of public access to data exist; and finally, hospital accreditation and licensing systems differ in each country. Conclusion Our findings indicate that if patients and policymakers are to compare the quality and safety of hospitals across Europe, then further work is urgently needed to agree the way forward. Until then, patients will not be able to make informed choices about where they receive their health care in different countries, and some governments will remain in the dark about the quality and safety of care available to their citizens as compared to that available in neighbouring countries.

A longitudinal, multi-level comparative study of quality and safety in European hospitals: the QUASER study protocol.

Backgroundalthough there is a wealth of information available about quality improvement tools and techniques in healthcare there is little understanding about overcoming the challenges of day-to-day implementation in complex organisations like hospitals. The Quality and Safety in Europe by Research (QUASER) study will investigate how hospitals implement, spread and sustain quality improvement, including the difficulties they face and how they overcome them.The overall aim of the study is to explore relationships between the organisational and cultural characteristics of hospitals and how these impact on the quality of health care; the findings will be designed to help policy makers, payers and hospital managers understand the factors and processes that enable hospitals in Europe to achieve-and sustain-high quality services for their patients.Methods/designin-depth multi-level (macro, meso and micro-system) analysis of healthcare quality policies and practices in 5 European countries, including longitudinal case studies in a purposive sample of 10 hospitals. The project design has three major features:• a working definition of quality comprising three components: clinical effectiveness, patient safety and patient experience• a conceptualisation of quality as a human, social, technical and organisational accomplishment• an emphasis on translational research that is evidence-based and seeks to provide strategic and practical guidance for hospital practitioners and health care policy makers in the European Union.Throughout the study we will adopt a mixed methods approach, including qualitative (in-depth, narrative-based, ethnographic case studies using interviews, and direct non-participant observation of organisational processes) and quantitative research (secondary analysis of safety and quality data, for example: adverse incident reporting; patient complaints and claims).Discussionthe protocol is based on the premise that future research, policy and practice need to address the sociology of improvement in equal measure to the science and technique of improvement, or at least expand the discipline of improvement to include these critical organisational and cultural processes. We define the organisational and cultural characteristics associated with better quality of care in a broad sense that encompasses all the features of a hospital that might be hypothesised to impact upon clinical effectiveness, patient safety and/or patient experience.

One size fits all? Mixed methods evaluation of the impact of 100% single-room accommodation on staff and patient experience, safety and costs

Background and objectives There is little strong evidence relating to the impact of single-room accommodation on healthcare quality and safety. We explore the impact of all single rooms on staff and patient experience; safety outcomes; and costs. Methods Mixed methods pre/post ‘move’ comparison within four nested case study wards in a single acute hospital with 100% single rooms; quasi-experimental before-and-after study with two control hospitals; analysis of capital and operational costs associated with single rooms. Results Two-thirds of patients expressed a preference for single rooms with comfort and control outweighing any disadvantages (sense of isolation) felt by some. Patients appreciated privacy, confidentiality and flexibility for visitors afforded by single rooms. Staff perceived improvements (patient comfort and confidentiality), but single rooms were worse for visibility, surveillance, teamwork, monitoring and keeping patients safe. Staff walking distances increased significantly post move. A temporary increase of falls and medication errors in one ward was likely to be associated with the need to adjust work patterns rather than associated with single rooms per se. We found no evidence that single rooms reduced infection rates. Building an all single-room hospital can cost 5% more with higher housekeeping and cleaning costs but the difference is marginal over time. Conclusions Staff needed to adapt their working practices significantly and felt unprepared for new ways of working with potentially significant implications for the nature of teamwork in the longer term. Staff preference remained for a mix of single rooms and bays. Patients preferred single rooms.

Inpatient diabetes care: complexity, resilience and quality of care

It is estimated that 10–15xa0% of UK hospital inpatients have diabetes. Poor glycemic control is a care quality problem that has been linked to organizational factors such as inadequate training, inadequate protocols, problems with communication and teamwork, and difficulty coordinating mealtimes. Interventions using specialist diabetes teams have been effective in addressing some of these problems and have led to increased staff and patient self-efficacy and reduced length of stay. The aim of this study was to investigate how inpatient diabetes care is delivered and how resilience is created and/or breaks down, and to identify the implications for quality improvement. In-depth interviews (nxa0=xa032) with diabetes specialist and non-specialist staff were conducted in an acute medical admissions environment in an 850-bed teaching hospital. The Critical Decision Method, a content-orientated knowledge elicitation technique, was adapted to guide interview schedules, which explored key decisions, gaps and discontinuities in care and strategies for work system improvement. Care is delivered through the coordination of a multilayered team of different professionals. Specialists provide expertise and problem solving through case-based reasoning using problem-solving skills acquired through past experience. Ward staff focus on processes and immediate patient needs and are more reliant on decision protocols. Gaps in care can occur and result in delays in referring to specialists and clinical inertia. Specialists are a key source of resilience in the system and bridge gaps by acting reactively to problems, proactively monitoring and anticipating problems, providing staff education, and patient support and education. Opportunities for supporting clinicians to bridge gaps in care were identified.

How do osteoporosis patients perceive their illness and treatment? Implications for clinical practice.

SummaryNon-adherence inhibits successful treatment of osteoporosis. This study used a theoretical framework to explore osteoporosis patients cognitive and emotional representations of their illness and medication, using both interviews and drawing. We recorded some misconceptions patients have about their condition and medication which could act as barriers to treatment adherence.PurposeDespite the high efficacy of current treatments in reducing fracture risk, poor adherence is still a problem in osteoporosis. This qualitative study aims to inform the development of a psychological intervention to increase adherence through the investigation of osteoporosis patients perceptions of their illness and medication. The self-regulation model (Leventhal) provided the framework for the study.MethodParticipants were 14 female outpatients from a London teaching hospital who suffer with osteoporosis or osteopenia. Data were collected using both semi-structured interviews and drawings. Drawings were used to elicit participants visual representations (imagery) of their condition.ResultsWe found that patients held illness and medication beliefs that were not in accord with current scientific evidence. Interviews revealed that participants had good knowledge of what osteoporosis is, but they had low understanding of the role of medication in reducing fracture risk, various concerns about the side effects of medication, poor understanding of the causes of osteoporosis and uncertainty about how it can be controlled. Additionally, drawings elicited more information about the perceived effects of osteoporosis and emotional reactions to the condition.ConclusionsOsteoporosis sufferers need a better understanding of their fracture risk and what they can do to control their condition. Concerns about medication need to be addressed in order to improve adherence, particularly in relation to the management of side effects. Since drawings of osteoporosis were found to arouse emotions, it is concluded that risk communication in osteoporosis could benefit from using visual images.