Mary Westbrook

Health service accreditation as a predictor of clinical and organisational performance: a blinded, random, stratified study

Background Despite the widespread use of accreditation in many countries, and prevailing beliefs that accreditation is associated with variables contributing to clinical care and organisational outcomes, little systematic research has been conducted to examine its validity as a predictor of healthcare performance. Objective To determine whether accreditation performance is associated with self-reported clinical performance and independent ratings of four aspects of organisational performance. Design Independent blinded assessment of these variables in a random, stratified sample of health service organisations. Settings Acute care: large, medium and small health-service organisations in Australia. Study participants Nineteen health service organisations employing 16 448 staff treating 321 289 inpatients and 1 971 087 non-inpatient services annually, representing approximately 5% of the Australian acute care health system. Main measures Correlations of accreditation performance with organisational culture, organisational climate, consumer involvement, leadership and clinical performance. Results Accreditation performance was significantly positively correlated with organisational culture (rho=0.618, p=0.005) and leadership (rho=0.616, p=0.005). There was a trend between accreditation and clinical performance (rho=0.450, p=0.080). Accreditation was unrelated to organisational climate (rho=0.378, p=0.110) and consumer involvement (rho=0.215, p=0.377). Conclusions Accreditation results predict leadership behaviours and cultural characteristics of healthcare organisations but not organisational climate or consumer participation, and a positive trend between accreditation and clinical performance is noted.

Rethinking clinical organisational structures : an attitude survey of doctors, nurses and allied health staff in clinical directorates

Objectives To examine assumptions made by proponents and critics of clinical directorate (CD) structures in hospitals. Proponents argue that CDs are supported by the health professionals who constitute them and confer organisational and clinical benefits compared with traditional structural configurations. Critics deny these benefits and suggest CDs can compromise clinicians by incorporating them into management, to their cost. We investigated the attitudes of health professionals working in CDs to gather and consider evidence for these claims. Methods A questionnaire survey of 227 health professionals (78 doctors, 89 nurses and 60 allied health) in two large hospitals in Australia that had implemented CDs three years previously. Results Respondents were more negative than positive about CDs. Significant attitudinal differences were found between professions. Doctors were the most negative and held their attitudes with the greatest certainty and intensity. Allied health staff were the most positive but their attitudes tended to lack strength or certainty. Nurses’ attitudes were polarised and intense but more positive than were doctors’. Increased organisational politics was cited by 58% of respondents as CDs’ most frequent effect, followed by improved accountability (48%) and dumping hard decisions on staff (39%). Only 26% thought patient care had improved. Conclusions Clinical directorates were designed to promote team approaches and to improve patient care delivery, but the results call for a rethink of what can be expected from structural reforms in organisations.

Experiences of health professionals who conducted root cause analyses after undergoing a safety improvement programme

Background: Research on root cause analysis (RCA), a pivotal component of many patient safety improvement programmes, is limited. Objective: To study a cohort of health professionals who conducted RCAs after completing the NSW Safety Improvement Program (SIP). Hypothesis: Participants in RCAs would: (1) differ in demographic profile from non-participants, (2) encounter problems conducting RCAs as a result of insufficient system support, (3) encounter more problems if they had conducted fewer RCAs and (4) have positive attitudes regarding RCA and safety. Design, setting and participants: Anonymous questionnaire survey of 252 health professionals, drawn from a larger sample, who attended 2-day SIP courses across New South Wales, Australia. Outcome measures: Demographic variables, experiences conducting RCAs, attitudes and safety skills acquired. Results: No demographic variables differentiated RCA participants from non-participants. The difficulties experienced while conducting RCAs were lack of time (75.0%), resources (45.0%) and feedback (38.3%), and difficulties with colleagues (44.5%), RCA teams (34.2%), other professions (26.9%) and management (16.7%). Respondents reported benefits from RCAs, including improved patient safety (87.9%) and communication about patient care (79.8%). SIP courses had given participants skills to conduct RCAs (92.8%) and improve their safety practices (79.6%). Benefits from the SIP were thought to justify the investment by New South Wales Health (74.6%) and committing staff resources (72.6%). Most (84.8%) of the participants wanted additional RCA training. Conclusions: RCA participants reported improved skills and commitment to safety, but greater support from the workplace and health system are necessary to maintain momentum.

Attitudes toward the large-scale implementation of an incident reporting system

OBJECTIVE An electronic Incident Information Management System implemented system-wide by the Department of Health, New South Wales, Australia was evaluated. We hypothesized that health professionals (i) would support the system via utilization and favourable attitudes and (ii) that their usage and attitudes would vary according to profession with nurses being most, and doctors least, favourably disposed. DESIGN, SETTING AND PARTICIPANTS An online, anonymous questionnaire survey of 2185 health practitioners. MAIN OUTCOME MEASURES Undertaking system training, satisfaction with training, reporting incidents, incident reporting rates since system introduction and attitude questions focusing on use, security and evaluation of the system and workplace safety cultures. RESULTS The first hypothesis received partial support. The majority of respondents had undertaken training and rated it highly. Most had reported incidents and maintained their previous reporting levels. Most attitudes regarding using the system and its security were favourable. Mixed attitudes were held about workplace safety cultures and the value of the system. Deficiencies in quality of reporting, feedback on incident reports and resources to analyse incident data were problems identified. The second hypothesis was confirmed. Nurses were most, and doctors least, likely to undertake training, report incidents and express favourable attitudes. Allied health responses were intermediate to those of the other professions. CONCLUSIONS The system implementation was relatively successful, but more so with some professions. Problems identified indicated that expectations as to the goals achievable in the short term were optimistic, but these are amenable to planned interventions.

Cultural and associated enablers of, and barriers to, adverse incident reporting

Aim Following the introduction of an electronic Incident Information Management System (IIMS) in New South Wales, Australia, the authors investigated enablers and barriers to the use of IIMS and factors associated with increased, static and decreased reporting rates. Methodology An online and paper-based, anonymous survey of 2185 health practitioners collected information about their reporting behaviour and experiences of enablers/barriers: training, system accessibility, ease of use, system security, feedback, perceived value of IIMS and workplace safety culture. Findings The 79.3% of respondents who reported on IIMS were distinguished from non-reporters by having undertaken IIMS training and evaluating this highly. Users reporting more incidents post-IIMS were more likely than those with static or decreased reporting rates to evaluate their training highly and to have experienced all enablers. Users reporting fewer incidents were least likely to do so. The relative likelihood of the three reporting groups experiencing various enablers was similar. Those most frequently experienced by all groups were system security and accessibility. Barriers most frequently encountered were more culturally embedded—for example, poor workplace safety culture. The ‘more’ reporting group actually reported most, and the ‘static’ group least, incidents. Limitations/implications The sample was large but not randomly selected, which limits the generalisability of findings. Practical implications Interventions to increase reporting should target provision of training that endorses and fosters conditions shown to enhance reporting rates. Originality Enablers to incident reporting have been shown to be associated not only with reporting per se but also with changes to reporting patterns and rates.

Does restructuring hospitals result in greater efficiency - an empirical test using diachronic data

Hospitals are being restructured more frequently. Increased cost efficiency is the usual justification given for such changes. All 20 major teaching hospitals in Australias two most populous states were investigated by classifying each over a 5-6 year period in terms of their cost efficiency (average cost per case weighted by Australian diagnosis-related group [AN-DRG] data and adjusted for inflation) and structure, categorized as traditional-professional (TP), clinical-divisional (CD), or clinical-institute (CI). In all, 12 hospitals changed structure during the study period. There was slight evidence that CD structures were more efficient than TP structures but this was not supported by other evidence. There were no significant differences in efficiency in the first or second years following changes from either TP to CD or TP to CI structures. All four hospitals changing from CD to CI structure became significantly less efficient. This may be due to frequency rather than type of change as they were the only hospitals that implemented two structural changes. Hospitals that changed or did not change structure were similar in efficiency at the beginning and at the end of the study period, in overall efficiency during the period, and in trends toward efficiency over time. The findings challenge those who advocate restructuring hospitals on the grounds of improving cost efficiency.

Gender differences in the symptoms and physical and mental well-being of dyspeptics: A population based study

Purpose: To compare women and men with dyspepsia in terms of symptoms, physical and mental well-being and the relationships between individual symptoms and well-being. Methods: A cross-sectional random telephone survey of 2300 Australians identified 748 people with dyspepsia who were interviewed regarding the number, types and severity of symptoms and physical (PCS) and mental well-being (MCS) measured by the SF-12. Results: There were no significant gender differences in number or average severity of symptoms. Bloating, nausea, and early satiety were significantly more frequent among women; food regurgitation and heartburn in men. Dyspeptics (PCS = 47.1, MCS = 46.0) had poorer physical (p < 0.001) and mental well-being (p < 0.001) than did non-dyspeptics (PCS = 53.5, MCS = 55.3). Among dyspeptics, women (PCS = 46.4, MCS = 44.7) had poorer physical (p < 0.05) and mental well-being (p < 0.001) than males (PCS = 47.9, MCS = 47.5). Some symptoms were associated with low well-being for both sexes e.g. nausea. For women retching was related to poor physical well-being, and food regurgitation, dysphagia, bloating and epigastric pain to poor mental well-being. Among men epigastric pain and heartburn were associated with poor physical well-being, acid regurgitation with poor mental well-being, and vomiting with both. Conclusions: Dyspeptics report poorer physical and mental well-being than do non-dyspeptics. The difference between groups is greater for mental well-being, especially among women. Both physical and social factors may contribute to gender differences.

A four-year, systems-wide intervention promoting interprofessional collaboration

BackgroundA four-year action research study was conducted across the Australian Capital Territory health system to strengthen interprofessional collaboration (IPC) though multiple intervention activities.MethodsWe developed 272 substantial IPC intervention activities involving 2,407 face-to-face encounters with health system personnel. Staff attitudes toward IPC were surveyed yearly using Heinemann et als Attitudes toward Health Care Teams and Parsell and Blighs Readiness for Interprofessional Learning scales (RIPLS). At studys end staff assessed whether project goals were achieved.ResultsOf the improvement projects, 76 exhibited progress, and 57 made considerable gains in IPC. Educational workshops and feedback sessions were well received and stimulated interprofessional activities. Over time staff scores on Heinemanns Quality of Interprofessional Care subscale did not change significantly and scores on the Doctor Centrality subscale increased, contrary to predictions. Scores on the RIPLS subscales of Teamwork & Collaboration and Professional Identity did not alter. On average for the assessment items 33% of staff agreed that goals had been achieved, 10% disagreed, and 57% checked neutral. There was most agreement that the study had resulted in increased sharing of knowledge between professions and improved quality of patient care, and least agreement that between-professional rivalries had lessened and communication and trust between professions improved.ConclusionsOur longitudinal interventional study of IPC involving multiple activities supporting increased IPC achieved many project-specific goals. However, improvements in attitudes over time were not demonstrated and neutral assessments predominated, highlighting the difficulties faced by studies targeting change at the systems level and over extended periods.

How important are quality and safety for clinician managers? Evidence from triangulated studies

Aims to discover the work hospital clinician managers think they do and observe them in practice. A total of 14 managerial interests and concerns were identified in focus group discussions. Clinician managers’ jobs are pressurised, and are more about negotiation and persuasion than command and control. Their work is of considerable complexity, pace and responsibility and it is predicated more on managing inputs (e.g. money and people) than care processes, systems, outputs and outcomes. Thus the capacity of clinicians in these roles to respond to reforms such as those envisaged in the Bristol Inquiry may be problematic. Qualitative studies are re‐affirmed as important in providing grounded insights into not only clinical activities, but also organisational behaviour and processes.

An empirical test of accreditation patient journey surveys: randomized trial.

OBJECTIVE To evaluate the effectiveness of utilizing the patient journey survey (PJS) method in healthcare accreditation processes. DESIGN Randomized trial of the PJS method in parallel with the current accreditation survey (CAS) method of the Australian Council on Healthcare Standards (ACHS). SETTING Acute healthcare organizations in Australia. PARTICIPANTS Seventeen organizations, 28 organizational staff, nine surveyors and 38 patients. MAIN OUTCOME MEASURES The results of each surveying method were compared. Participants provided feedback, via 18 interviews and 40 questionnaire surveys, about the benefits and disadvantages of a PJS compared to a CAS. RESULTS The PJS method is not as comprehensive as the CAS method for accreditation assessment. In matched assessments the majority of items were rated lower by the PJS method than by the CAS. PJSs were shown to be appropriate for assessing mandatory clinical criteria, but were less effective for assessing corporate and support criteria. The two methods diverged in their final assessments of which organizations met the accreditation threshold. Participants endorsed the use of PJSs within accreditation processes. CONCLUSIONS The PJS methodology complements but is not a substitute for existing accreditation methods. There is significant stakeholder support for the inclusion of the PJS method within the current accreditation programme.