Johan Hellings

Systematic review and meta-analysis of the effect of the World Health Organization surgical safety checklist on postoperative complications

The World Health Organization (WHO) surgical safety checklist (SSC) was introduced to improve the safety of surgical procedures. This systematic review evaluated current evidence regarding the effectiveness of this checklist in reducing postoperative complications.

Incidence and preventability of adverse events requiring intensive care admission: a systematic review.

RATIONALE, AIMS AND OBJECTIVES Adverse events are unintended patient injuries or complications that arise from health care management resulting in death, disability or prolonged hospital stay. Adverse events that require critical care are a considerable financial burden to the health care system, but also their global impact on patients and society is probably underestimated. The objectives of this systematic review were to synthesize the best available evidence regarding the estimates of the incidence and preventability of adverse events that necessitate intensive care admission, to determine the type and consequences [mortality, length of intensive care unit (ICU) stay and costs] of these adverse events. METHODS MEDLINE (from 1966 to present), EMBASE (from 1974 to present) and CENTRAL (version 1-2010) were searched for studies reporting on unplanned admissions on ICUs. Several other sources were searched for additional studies. Only quantitative studies that used chart review for the detection of adverse events requiring intensive care admission were considered for eligibility. For the purposes of this systematic review, ICUs were defined as specialized hospital facilities which provide continuous monitoring and intensive care for acutely ill patients. Studies that were published in the English, Dutch, German, French or Spanish language were eligible for inclusion. Two reviewers independently extracted data and assessed the methodological quality of the included studies. RESULTS A total of 27 studies were reviewed. Meta-analysis of the data was not appropriate because of methodological and statistical heterogeneity between studies; therefore, results are presented in a descriptive way. The percentage of surgical and medical adverse events that required ICU admission ranged from 1.1% to 37.2%. ICU readmissions varied from 0% to 18.3%. Preventability of the adverse events varied from 17% to 76.5%. Preventable adverse events are further synthesized by type of event. Consequences of the adverse events included a mean length of ICU stay that ranged from 1.5 days to 10.4 days for the patients first stay in ICU and mortality percentages between 0% and 58%. CONCLUSIONS Adverse events are an important reason for (re)admission to the ICU and a considerable proportion of these are preventable. It was not possible to estimate an overall incidence and preventability rate of these events as we found considerable heterogeneity. To decrease adverse events that necessitate ICU admission, several systems are recommended such as early detection of patients with clinical instability on general wards and the implementation of rapid response teams. Step-down or intermediate care units could be a useful strategy for patients who require monitoring to avoid ICU readmissions. However, the effectiveness of such systems needs to be investigated.

Barriers and facilitators related to the implementation of surgical safety checklists: a systematic review of the qualitative evidence

Objective The objective of this review is to obtain a better understanding of the user-related barriers against, and facilitators for, the implementation of surgical safety checklists. Methods We searched MEDLINE for articles describing stakeholders’ perspectives regarding, and experiences with, the implementation of surgical safety checklists. The quality of the papers was assessed by means of the Qualitative Assessment and Review Instrument. Thematic synthesis was used to integrate the emergent descriptive themes into overall analytical themes. Results The synthesis of 18 qualitative studies indicated that implementation requires change in the workflow of healthcare professionals as well as in their perception of the checklist and the perception of patient safety in general. The factors impeding or advancing the required change concentrated around the checklist, the implementation process and the local context. We found that the required safety checks disrupt operating theatre staffs’ routines. Furthermore, conflicting priorities and different perspectives and motives of stakeholders complicate checklist implementation. When approaching the checklist as a simple technical intervention, the expectation of cooperation between surgeons, anaesthetists and nurses is often not addressed, reducing the checklist to a tick-off exercise. Conclusions The complex reality in which the checklist needs to be implemented requires an approach that includes more than eliminating barriers and supporting facilitating factors. Implementation leaders must facilitate team learning to foster the mutual understanding of perspectives and motivations, and the realignment of routines. This paper provides a pragmatic overview of the user-related barriers and facilitators upon which theories, hypothesising potential change strategies and interactions, can be developed and tested empirically.

A nationwide Hospital Survey on Patient Safety Culture in Belgian hospitals: setting priorities at the launch of a 5-year patient safety plan

Objective To measure patient safety culture in Belgian hospitals and to examine the homogeneous grouping of underlying safety culture dimensions. Methods The Hospital Survey on Patient Safety Culture was distributed organisation-wide in 180 Belgian hospitals participating in the federal program on quality and safety between 2007 and 2009. Participating hospitals were invited to submit their data to a comparative database. Homogeneous groups of underlying safety culture dimensions were sought by hierarchical cluster analysis. Results 90 acute, 42 psychiatric and 11 long-term care hospitals submitted their data for comparison to other hospitals. The benchmark database included 55 225 completed questionnaires (53.7% response rate). Overall dimensional scores were low, although scores were found to be higher for psychiatric and long-term care hospitals than for acute hospitals. The overall perception of patient safety was lower in French-speaking hospitals. Hierarchical clustering of dimensions resulted in two distinct clusters. Cluster I grouped supervisor/manager expectations and actions promoting safety, organisational learning–continuous improvement, teamwork within units and communication openness, while Cluster II included feedback and communication about error, overall perceptions of patient safety, non-punitive response to error, frequency of events reported, teamwork across units, handoffs and transitions, staffing and management support for patient safety. Conclusion The nationwide safety culture assessment confirms the need for a long-term national initiative to improve patient safety culture and provides each hospital with a baseline patient safety culture profile to direct an intervention plan. The identification of clusters of safety culture dimensions indicates the need for a different approach and context towards the implementation of interventions aimed at improving the safety culture. Certain clusters require unit level improvements, whereas others demand a hospital-wide policy.

Economic Impact of Integrated Care Models for Patients with Chronic Diseases: A Systematic Review

OBJECTIVES To assess the costs and potential financial benefits of integrated care models for patients with chronic diseases, that is, type 2 diabetes mellitus, schizophrenia, and multiple sclerosis, respectively. METHODS A systematic search of the literature was performed using EMBASE, MEDLINE, and Web of Science. Studies that conducted a cost analysis, considered at least two components of the chronic care model, and compared integrated care with standard care were included. RESULTS Out of 575 articles, 26 were included. Most studies examined integrated care models for type 2 diabetes mellitus (n = 18) and to a lesser extent for schizophrenia (n = 6) and multiple sclerosis (n = 2). Across the three disease groups, the incremental cost per patient per year ranged from - €3860 to + €613.91 (x¯ = - €533.61 ± €902.96). The incremental cost for type 2 diabetes mellitus ranged from - €1507.49 to + €299.20 (x¯ = - €518.22 ± + €604.75), for schizophrenia from - €3860 to + €613.91 (x¯ = - €677.21 ± + €1624.35), and for multiple sclerosis from - €822 to + €339.43 (x¯ = - €241.29 ± + €821.26). Most of the studies (22 of 26 [84.6%]) reported a positive economic impact of integrated care models: for type 2 diabetes mellitus (16 of 18 [88.9%]), schizophrenia (4 of 6 [66.7%]), and multiple sclerosis (1 of 2 [50%]). CONCLUSIONS In this systematic literature review, predominantly positive economic impacts of integrated care models for patients with chronic diseases were found.

Variability of Patient Safety Culture in Belgian Acute Hospitals

Objectives The aim of this study was to measure differences in safety culture perceptions within Belgian acute hospitals and to examine variability based on language, work area, staff position, and work experience. Methods The Hospital Survey on Patient Safety Culture was distributed to hospitals participating in the national quality and safety program (2007–2009). Hospitals were invited to participate in a comparative study. Data of 47,136 respondents from 89 acute hospitals were used for quantitative analysis. Percentages of positive response were calculated on 12 dimensions. Generalized estimating equations models were fitted to explore differences in safety culture. Results Handoffs and transitions, staffing, and management support for patient safety were considered as major problem areas. Dutch-speaking hospitals had higher odds of positive perceptions for most dimensions in comparison with French-speaking hospitals. Safety culture scores were more positive for respondents working in pediatrics, psychiatry, and rehabilitation compared with the emergency department, operating theater, and multiple hospital units. We found an important gap in safety culture perceptions between leaders and assistants within disciplines. Administration and middle management had lower perceptions toward patient safety. Respondents working less than 1 year in the current hospital had more positive safety culture perceptions in comparison with all other respondents. Conclusions Large comparative databases provide the opportunity to identify distinct high and low scoring groups. In our study, language, work area, and profession were identified as important safety culture predictors. Years of experience in the hospital had only a small effect on safety culture perceptions.

Infection prevention and control strategies in the era of limited resources and quality improvement: a perspective paper.

This paper aims to describe, using an evidence-based approach, the importance of and the resources necessary for implementing effective infection prevention and control (IPC) programmes. The intrinsic and explicit values of such strategies are presented from a clinical, health-economic and patient safety perspective. Policy makers and hospital managers are committed to providing comprehensive, accessible, and affordable healthcare of high quality. Changes in the healthcare system over time accompanied with variations in demographics and case-mix have considerably affected the availability, quality and ultimately the safety of healthcare. The main goal of an IPC programme is to prevent and control healthcare-associated infections (HAI). Many patient-, healthcare provider-, and organizational factors are associated with an increased risk for acquiring HAIs and may impact both the quality and outcome of patient care. Evidence has been published in support of having an effective IPC programme. It has been estimated that about one-third of HAIs could be prevented if key elements of the evidence-based recommendations for IPC are adequately introduced and followed. However, several healthcare agencies from over the world have reported deficits in the essential resources and components of current IPC programmes. To meet its main goal, staffing, training, and infrastructure requirements are needed. Nevertheless, and given the economic crisis, policy makers and hospital managers may be tempted to not increase or even to reduce the budget as it consumes resources and does not generate sufficient visible revenue. IPC is a critical issue in patient safety, as HAIs are by far the most common complication affecting admitted patients. The significant clinical and health-economic burden HAIs place on the healthcare system speak to the importance of getting introduced effective IPC programmes.

Measuring safety culture in belgian psychiatric hospitals: validation of the dutch and French translations of the hospital survey on patient safety culture.

OBJECTIVES To measure safety culture in Belgian psychiatric hospitals on 12 dimensions and to examine the psychometric properties of the Dutch and French translations of the Hospital Survey on Patient Safety Culture (HSPSC) for use in psychiatric hospitals. METHODS The authors analyzed 6,658 completed questionnaires (70.5% response rate) from a baseline measurement (2007-2009) in 44 psychiatric hospitals and 8,353 questionnaires (71.5% response rate) from a follow-up measurement (2011) in 46 psychiatric hospitals. Psychometric properties of the questionnaire were evaluated using item analysis, exploratory factor analysis (EFA), confirmatory factor analysis (CFA), reliability analysis (Cronbachs alpha), and analysis of composite scores and inter-correlations. RESULTS For both translations, CFA showed an acceptable fit with the original 12-dimensional model. For the Dutch and French translations, EFA showed a 10-factor and a 9-factor optimal measurement model, respectively. Cronbachs alpha indicated an acceptable level of reliability (≥ 0.70) for 7 of 12 dimensions. Most pair-wise correlations were significant and <0.5, implying good construct validity. CONCLUSION The Dutch and French translations of the HSPSC were found tobe valid and reliable for measuring patient safety culture in psychiatric hospitals. Our results also suggest the use of combinations of specific dimensions as recommended in previous research.

Does lean management improve patient safety culture? An extensive evaluation of safety culture in a radiotherapy institute

PURPOSE The importance of a safety culture to maximize safety is no longer questioned. However, achieving sustainable culture improvements are less evident. Evidence is growing for a multifaceted approach, where multiple safety interventions are combined. Lean management is such an integral approach to improve safety, quality and efficiency and therefore, could be expected to improve the safety culture. This paper presents the effects of lean management activities on the patient safety culture in a radiotherapy institute. METHODS Patient safety culture was evaluated over a three year period using triangulation of methodologies. Two surveys were distributed three times, workshops were performed twice, data from an incident reporting system (IRS) was monitored and results were explored using structured interviews with professionals. Averages, chi-square, logistical and multi-level regression were used for analysis. RESULTS The workshops showed no changes in safety culture, whereas the surveys showed improvements on six out of twelve dimensions of safety climate. The intention to report incidents not reaching patient-level decreased in accordance with the decreasing number of reports in the IRS. However, the intention to take action in order to prevent future incidents improved (factorial survey presented β: 1.19 with p: 0.01). CONCLUSIONS Due to increased problem solving and improvements in equipment, the number of incidents decreased. Although the intention to report incidents not reaching patient-level decreased, employees experienced sustained safety awareness and an increased intention to structurally improve. The patient safety culture improved due to the lean activities combined with an organizational restructure, and actual patient safety outcomes might have improved as well.

Evolution of patient safety culture in Belgian acute, psychiatric and long-term care hospitals

BackgroundIn Belgium, the federal government launched a national program to support hospitals for implementing quality and patient safety strategies. One of the main objectives in the federal program is the development of a safety culture. The purpose of this study was to examine to what extent the hospitals’ safety culture evolved after participating in the federal program and to explore predictor variables of safety culture.MethodsIn a cross-sectional follow-up design, safety culture was measured in the Belgian acute, psychiatric and long-term care hospitals using validated translations of the Hospital Survey on Patient Safety Culture in Flemish and French. For both nationwide measurements, hospitals were invited to participate in a benchmark research organized by an academic institution (in 2008 and 2012). Generalized Estimating Equations models were fitted to examine the effect of predictor variables on safety culture perceptions.ResultsThe Belgian safety culture database contains data from 115 827 respondents from 176 hospitals. For 111 hospitals that participated in both benchmarks it was possible to calculate changes in safety culture. The response rate for the second measurement (52.2%) was comparable to the response rate in the first measurement (51.0%). Improvements were observed for most safety culture dimensions with a major significant improvement for ‘Management support for patient safety’. Although ‘Handoffs and transitions’ and ‘Frequency of events reported’ were key areas within the federal program, a decline was observed for these dimensions. Work area, staff position, language (regional context of hospital), hospital type and hospital statute were found to have important effects on safety culture perceptions. Hospital size and work experience, showed to have less effect on safety culture scores.ConclusionsLarge comparative safety culture databases allow identifying patterns and trends. Our findings on variations in safety culture perceptions between types of hospitals, hospital units and professional groups implicate the need for a tailor-made approach for safety culture improvement. Future research should focus on enriching the evidence of the effectiveness of safety culture strategies and linking of safety culture and outcomes of care in order to assess the practical validity of safety culture surveys.