Lorna Flynn

Intentional Rounding: a staff-led quality improvement intervention in the prevention of patient falls

AIMS AND OBJECTIVES This study designed and evaluated the use of a specific implementation strategy to deliver a nursing staff-led Intentional Rounding intervention to reduce inpatient falls. BACKGROUND Patient falls are a common cause of harm during hospital treatment. Intentional Rounding has been proposed as a potential strategy for prevention, but has not received much objective evaluation. Previous work has suggested that logical interventions to improve patient care require an integrated implementation strategy, using teamwork training and systems improvement training, to instigate positive change and improvement. METHODS Customised Intentional Rounding was implemented and evaluated as part of a staff-led quality improvement intervention to reduce falls on a neuroscience ward. Intentional Rounding was instigated using a prespecified implementation strategy, which comprised of: (1) engagement and communication activities, (2) teamwork and systems improvement training, (3) support and coaching and (4) iterative Plan-Do-Check-Act cycles. Process (compliance with hourly visiting to patients by staff) and outcome (incidence of falls) measures were recorded pre- and postintervention. Falls measured on the active ward were compared with incidence of falls in 50 wards across the rest of the same Trust. RESULTS There was a 50% reduction in patient falls on the active ward vs. a minimal increase across the rest of the Trust (3·48%). Customised Intentional Rounding, designed by staff specifically for the context, appeared to be effective in reducing patient falls. CONCLUSIONS Improvement programmes based on integrating teamwork training and staff-led systems redesign, together with a preplanned implementation strategy, can deliver effective change and improvement. RELEVANCE TO CLINICAL PRACTICE This study demonstrates, through the implementation of a specific strategy, an effective improvement intervention to reduce patient falls. It provides insight into the effective design and practical implementation of integrated improvement programmes to reduce risk to patients at the frontline.

The Safer Delivery of Surgical Services Program (S3): Explaining Its Differential Effectiveness and Exploring Implications for Improving Quality in Complex Systems.

Objective: To analyze the challenges encountered during surgical quality improvement interventions, and explain the relative success of different intervention strategies. Summary Background Data: Understanding why and how interventions work is vital for developing improvement science. The S3 Program of studies tested whether combining interventions addressing culture and system was more likely to result in improvement than either approach alone. Quantitative results supported this theory. This qualitative study investigates why this happened, what aspects of the interventions and their implementation most affected improvement, and the implications for similar programs. Methods: Semistructured interviews were conducted with hospital staff (23) and research team members (11) involved in S3 studies. Analysis was based on the constant comparative method, with coding conducted concurrently with data collection. Themes were identified and developed in relation to the program theory behind S3. Results: The superior performance of combined intervention over single intervention arms appeared related to greater awareness and ability to act, supporting the S3 hypothesis. However, we also noted unforeseen differences in implementation that seemed to amplify this difference. The greater ambition and more sophisticated approach in combined intervention arms resulted in requests for more intensive expert support, which seemed crucial in their success. The contextual challenges encountered have potential implications for the replicability and sustainability of the approach. Conclusions: Our findings support the S3 hypothesis, triangulating with quantitative results and providing an explanatory account of the causal relationship between interventions and outcomes. They also highlight the importance of implementation strategies, and of factors outside the control of program designers.

Improving emergency surgical care for patients with right iliac fossa pain at a regional scale: A quality improvement study using the Supported Champions implementation strategy.

INTRODUCTION Methods to improve clinical systems safety suffer from significant difficulties in implementation and scaling up. We used an upscaling implementation strategy entitled Supported Champions in a quality and safety improvement programme for emergency surgery at regional level, focusing on patients with right iliac fossa pain. METHODS A before-after study was conducted across four acute NHS Trusts: A 6 month intervention phase was preceded and followed by 3 months of data collection. An established Human Factors intervention was led at each Trust by a small group of staff selected as Champions. Champions received training in teamwork and systems improvement and were supported by Human Factors experts. The primary improvement aim was to expedite surgery for patients with sepsis, using Royal College of Surgeons emergency surgery guidelines as the measure. Additional outcomes studied included length of inpatient stay and 30-day readmission rates. RESULTS Breaches of RCS urgency guidelines decreased markedly from 13.7% of operated patients pre-intervention to 3.5% post-intervention (p = 0.000). Mean time from booking to incision decreased in three of the four sites, whilst median length of stay increased in 3 of 4. Overall 30-day readmission rate remained stable (7.84% pre-intervention versus 7.31% post-intervention, p = 0.959). DISCUSSION The Supported Champions model allowed all surgical teams to reduce delay for septic patients by more than 50%, using distinct Quality Improvement strategies to address local issues. Improvement was implemented in 4 diverse settings with a quarter of the level of expert input previously used in a single hospital.