The integration of health care services is intended to improve the continuity, quality and efficiency of care provided to patients. This is a challenging goal and presumes that there is much about the current health care system that needs improvement. Health maintenance organisations (HMOs) provide a continuum of services including disease prevention, primary, secondary and tertiary acute care services, in exchange for a fixed membership fee per member per month. Community Care Retirement Communities (CCRC) provides a package of services, including housing, health care, and social services, to older adults. The chapter examines the efforts in the United States and the United Kingdom to integrate health services. It is apparent that fully integrated systems are more rare than appears at first glance. Thus the much more challenging task of developing fully integrated systems may be reserved for those sub-populations with high levels of medical need or special circumstances.
The impact of an ageing population on health resources has been widely discussed and debated within a number of different forums: government, academia, and various health care settings, e.g. hospital and community. Despite the growing recognition that the ageing population represents a major challenge in health care, there has been no major government policy initiative on this topic. This chapter describes the background to this legislation, its implementation in the nursing home environment, its influence on nursing home care delivery, and possible lessons for the UK. Prescribing behaviour in US nursing homes has changed, and in fact, changes were observed prior to the formal implementation of the regulations i.e. anticipatory changes. Regulation of nursing homes is also governed by legislation in the form of the Registered Homes Act and accompanying regulations in England and Wales, and equivalent legislation in Northern Ireland and Scotland. Interdisciplinary working should be a component of any new model of nursing home care.
Community care is a vital component of care for older people and the need to evaluate the outcomes of health and social care has become increasingly important. Several studies have looked at the ingredients older people consider important for their overall quality of life. Bowling, for example, compared responses from older and younger age groups in a UK national interview survey. Some have argued against the use of self-administered postal questionnaires in an older population. Others have shown that postal surveys amongst older people can achieve high response rates in certain settings, or where the survey is seen as directly relevant to respondent's interests and concerns. The Royal College of Physicians of London and the British Geriatrics Society recently used the domains for assessment in the elderly recommended by the World Health Organisation to select a set of standardised assessment scales for older people.
Health systems around the world are faced with the challenge of improving the efficiency, effectiveness and responsiveness of service delivery. Pasmore defines organisational technology as consisting of the tools, techniques, devices, artefacts, methods, configurations, procedures and knowledge used to acquire inputs, transform inputs to outputs and provide services to clients. Socio-technical theory provides a framework to examine the adaptation of new technology into the organisational routines for the delivery of clinical care. A recent review conducted by the NHS Research and Development Health Technology Assessment Programme (HTAP) highlights the flaws in the existing research and development model of clinical care technologies. The principle of emergent competition provides the foundation for a new model of process innovation for clinical care technology. The durable technology sector in health care, through a combination of intellectual property rights and regulatory requirements for proof of effectiveness has produced an extraordinary flow of new effective technologies.
It is generally accepted that the eponymous ancestors of Maori arrived in Aotearoa in 800AD and were of Melanesian/Polynesian descent. Since 1840, the Crown and Maori have disputed the interpretation and consequent prudent practical implementation of the Treaty. The result is that both 'partners' have frequently requested the Court to adjudicate on matters related to recognising the Treaty and applying it in good faith and for the benefit of the Maori people. Partnership is a major strategic development theme, which can provide powerful opportunities for robust participation and direct benefits. The objective of Maori provider and workforce development is to support the establishment, consolidation and continuation of quality Maori health service providers and health professionals within the sector. In New Zealand, some innovative initiatives have been created which enable Maori participation to occur at each level of the health sector, that is, at the funder, provider and consumer levels.
In industrialised countries, quality of care is widely debated in the context of health care reform, and increasingly this is also becoming the case in middle- and low-income countries. The Alma Ata Declaration had a direct influence in developing countries in focusing efforts to improve access to health services at primary health care (PHC) level. Budget implications of policy statements need to be assessed at an early stage so that implementation activities can be programmed into annual work plans of regions and districts. Successful policy implementation requires continuity of resourcing and will not be sustainable on the basis of special funding or one-off budget allocations. Adopting an off-the-shelf package might be evidence of a government's response to public demand for better services. Quality assurance provides an approach with a great deal of potential for middle- and low-income countries and evidence from Central America and Ghana has demonstrated that it is possible to improve quality within existing resource constraints.
Health care quality is high on the agenda in most developed nations and many developing ones. This chapter explores some of the factors behind this activity and enumerates the key strategies deployed in pursuit of change. Michael Power has written of living in an 'audit society' and with the subtitle 'rituals of verification' one can surmise that his analysis disputes the instrumentality of the approach. Health care professionals claim special knowledge about what works in health care and consequently have always claimed rights to professional self-regulation. Public release has undoubtedly stimulated a greater intensity of effort aimed at improving the quality, quantity and meaningfulness of the data available. Central to evidence-based practice is the capacity for ongoing individual learning - not just of facts, but also of skills. Effective health care policy is that which sets an environment which encourages the emergence of self-governing organisations dedicated to clinical excellence, innovation and learning.
A representative survey of antenatal care in Scotland in 1989 demonstrated a very standard package of consultant-led shared care with virtually all deliveries taking place in hospital settings. In Scotland CRAG-SCOTMEG's Working Group on Maternity Services had given recommendations for planning and provision of maternity care. In exploring the difficulties of interpreting trial evidence of clinical effectiveness and costs as well as patient and staff satisfaction in alternative models of maternity care, some of the possible barriers to implementation may have been highlighted. There is no single objectively correct definition of equity and the equity of access by patient preference as described above, is only one possible definition. NHS maternity services have been at the forefront of progress towards efficacy in health care provision. Recent government policies continue to seek clinical effectiveness and efficiency throughout all NHS services and also emphasise that care should be patient-focused, with improved continuity, and include the patient in choices and decision-making.
The U.S. experience of public disclosure of information about the performance ot health care providers and health plans is an example of a health policy initiative that has lessons for other countries. Public disclosure should be seen as an evolutionary process and health professionals and their representative bodies should play a part in the process.
OBJECTIVES:Implementation of quality improvement programmes may suffer if the stakeholders involved do not share a common understanding of the theory of change or do not accept it as legitimate. We aimed to identify how strategic stakeholders understood and responded to the first phase of the Health Foundation's Safer Patients Initiative, a programme aimed at making hospitals safer for patients in the UK.METHODS:Semistructured telephone interviews were conducted with 60 strategic-level hospital stakeholders and with five stakeholders involved in commissioning, designing and introducing the initiative. Analysis was based on the constant comparative method.RESULTS:The aims of the initiative were seen as legitimate and sound by most hospital stakeholders, and the theory of change was generally understood and accepted, but seven hospital stakeholders were unable to describe it. Although participants had specific doubts, particularly relating to feasibility of implementation and scientific legitimacy of some elements of the initiative, overall there was a broadly shared vision and commitment to the principles and practices associated with the theory of change, and considerable enthusiasm and optimism. Contestations about the legitimacy and relevance of the initiative among front-line staff, local resistance to changes that went against established norms, and resource and structural issues were, however, seen as potentially threatening to implementation.CONCLUSIONS:It is possible to get strategic-level individuals, even when widely dispersed, to understand and agree upon a theory of change that can be used in their organisations. These individuals are also able to recognise the contexts of negotiation in which programmes of change are enacted.
Background In The Netherlands, health professionals have created a doctor-driven standardised system to report and analyse adverse outcomes (AO). The aim is to improve healthcare by learning from past experiences. The key elements of this system are (1) an unequivocal definition of an adverse outcome, (2) appropriate contextual information and (3) a three-dimensional hierarchical classification system.Objectives First, to assess whether routine doctor-driven AO reporting is feasible. Second, to investigate how doctors can learn from AO reporting and analysis to improve the quality of care.Methods Feasibility was assessed by how well doctors reported AO in the surgical department of a Dutch university hospital over a period of 9 years. AO incidence was analysed per patient subgroup and over time, in a time-trend analysis of three equal 3-year periods. AO were analysed case by case and statistically, to learn lessons from past events.Results In 19 907 surgical admissions, 9189 AOs were reported: one or more AO in 18.2% of admissions. On average, 55 lessons were learnt each year (in 4.3% of AO). More AO were reported in P3 than P1 (OR 1.39 (1.23-1.57)). Although minor AO increased, fatal AO decreased over time (OR 0.59 (0.45-0.77)).Conclusions Doctor-driven AO reporting is shown to be feasible. Lessons can be learnt from case-by-case analyses of individual AO, as well as by statistical analysis of AO groups and subgroups (illustrated by time-trend analysis), thus contributing to the improvement of the quality of care. Moreover, by standardising AO reporting, data can be compared across departments or hospitals, to generate (confidential) mirror information for professionals cooperating in a peer-review setting.
BACKGROUND:Patients have been shown to report accurate observations of medical errors and adverse events. Various methods of introducing patient reporting into patient safety systems have been published with little consensus among researchers on the most effective method. Terminology for use in patient safety reporting has yet to be standardised.METHODS:Two databases, PubMed and MEDLINE, were searched for literature on patient reporting of medical errors and adverse events. Comparisons were performed to identify the optimal method for eliciting patient initiated events.RESULTS:Seventeen journal publications were reviewed by patient population, type of healthcare setting, contact method, reporting method, duration, terminology and reported response rate.CONCLUSION:Few patient reporting studies have been published, and those identified in this review covered a wide range of methods in diverse settings. Definitive comparisons and conclusions are not possible. Patient reporting has been shown to be reliable. Higher incident rates were observed when open-ended questions were used and when respondents were asked about personal experiences in hospital and primary care. Future patient reporting systems will need a balance of closed-ended questions for cause analysis and classification, and open-ended narratives to allow for patient's limited understanding of terminology. Establishing the method of reporting that is most efficient in collecting reliable reports and standardising terminology for patient use should be the focus of future research.
Background There is growing international interest in involving patients in interventions to promote and support them in securing their own safety. This paper reports a systematic review of evaluations of the effectiveness of interventions that have been used with the explicit intention of promoting patient involvement in patient safety in healthcare. Methods The authors searched Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, CENTRAL, CINAHL, EMBASE, HMIC, MEDLINE, MEDLINE in-process, PsycINFO and ASSIA to August 2008. We also searched databases of reports, conference proceedings, grey literature, ongoing research and relevant patient safety organisations, and hand-searched two journals. Meta-analysis of the data was not appropriate; therefore, studies were categorised according to how the interventions encouraged patients' actions to improve safety—informing the management plan, monitoring and ensuring safe delivery of treatment (by health professional and by self), making systems safer—and were critiqued in a narrative manner. Findings The authors identified 14 individual experimental and quasiexperimental studies plus one systematic review. The majority of studies fell into the monitoring and ensuring safe delivery of treatment by self category and were all related to enhancing medication safety. Authors reported improved patient safety incident outcomes for the intervention groups compared with controls where the interventions aimed to encourage patient involvement in: (1) monitoring and ensuring safe delivery of treatment by self (self-management of anticoagulation, ‘easy’ read information leaflet, nurse-led education to promote self-medication in hospital, patient package insert using lay terminology); (2) informing the management plan/monitoring and ensuring safe delivery of treatment by self (individualised teaching plan by nurse, pharmacist counselling). It was not possible to draw any clear conclusions as to the effectiveness of the interventions (with the exception of one specific aspect of self-medication, that is, self-management of anticoagulation) due to concerns about the methodological quality of the studies. Conclusions There is limited evidence for the effectiveness of interventions designed to promote patient involvement on patient safety incidents and in general is poor quality. Existing evidence is confined to the promotion of safe self-management of medication, most notably relating to the self-management of oral anticoagulants.
Background Legislation enacted in the US State of North Carolina in 2003 requires all licenced nursing homes to report all medication errors. In 2007, nursing homes were encouraged to voluntarily convert from aggregate reporting to a new online system where they reported each individual error.Methods A new optional web-based reporting tool was made available to all 393 North Carolina nursing homes to submit error reports for each distinct medication error as they occurred during the year.Results A total of 5823 medication error reports were submitted by 203 sites (52%) using the new system during the reporting year, a median of 18 error reports per site. Of the 5823 error reports, 612 (10.5%) were categorised as serious. Serious errors were more likely to be caused by drugs given to the wrong patient (RR 4.39, CI 3.7 to 5.2), lab-work error (RR 2.40, CI 1.4 to 4.0), wrong product given (RR 2.22, CI 1.8 to 2.8) and medication overdoses (RR 1.49, 1.2 to 1.8). Serious errors were more likely to occur on second shift (RR 1.32, 1.1 to 1.5). Common medications that are involved in the most serious errors include warfarin (RR 2.58, CI 2.09 to 3.18) and insulin (RR 2.35, CI 1.86 to 2.97), and oxycodone combinations (RR 1.48, CI 1.07 to 2.06).Conclusions Data collected from a nursing home medication error system can provide helpful information on serious errors that can be used to focus patient safety efforts to reduce harm. This improved information will be useful in nursing homes for continuous quality improvement efforts.
OBJECTIVE:Better outcomes for major depressive disorder (MDD) are associated with proactive treatment, including timely follow-up, systematic assessment and treatment changes for inadequate improvement. The effectiveness of an intervention to facilitate proactive treatment for MDD in a resident psychopharmacology clinic was studied.METHODS:A quality improvement program with administrative process changes to improve flow and a 40-week pre/post study to evaluate the effect of education and feedback was conducted. A systematic assessment and reengineered scheduling system were implemented. During the first 20 weeks, baseline data were collected; during the second 20 weeks, feedback to residents and attending psychiatrists about adherence to evidence-based treatment recommendations was added.RESULTS:Reengineering our system to improve flow was successful. By linking outcomes collection to completion of billing sheets, outcomes at 90% of visits for MDD throughout the 40-week study was assessed. By centralising our scheduling system, the percentage of active-phase patients with MDD seen for follow-up within 6 weeks was improved from 19% to 59%. In response to feedback, residents did not make significant changes to their overall practice patterns. Patient outcomes did not improve as a result of feedback to residents. Residents did improve their practice patterns for a subset of patients including those without comorbid psychiatric disorders and those whose depressive episodes had lasted <1 year.CONCLUSIONS:Improving administrative processes for the treatment of patients with MDD resulted in rapid changes that were associated with improvements in the delivery of evidence-based care. Feedback to residents was more difficult and less successful.
Background Little is known of the incidence of adverse events in the paediatric intensive care unit (PICU). Perceived incidence may be dependent on data-collection methods.Objective To determine the incidence of adverse events by voluntary reporting and systematic enquiry.Methods Adverse events in PICU were recorded contemporaneously by systematic enquiry with bedside nurses and attending doctors, and compared with data submitted voluntarily to the hospital's quality and safety unit. Events were classified as insignificant, minor, moderate, major and catastrophic or lethal, and assigned origins as medical/surgical diagnosis or management, medical/surgical procedures, medication or miscellaneous.Results Among 740 patients, 524 adverse events (mean 0.71 per patient) occurred in 193 patients (26.1%). Systematic enquiry detected 405 (80%) among 165 patients and were classified by one investigator as insignificant 30 (7%); minor 100 (25%); moderate 160 (37%); major 103(25%) and catastrophic 12 (3%). The coefficient of agreement (kappa) of severity between the two investigators was 0.82 (95% CI 0.78-0.87). Voluntary reporting detected 166 (32%) adverse events among 100 patients, of which 119 were undetected by systematic reporting. Forty-nine events (9%) were detected by both methods. The number and severity of events reported by the two methods were significantly different (p<0.0001). Voluntary reporting, mainly by nurses, did not capture major, severe or catastrophic events related to medical/surgical diagnosis or management.Conclusions Neither voluntary reporting nor systematic enquiry captures all adverse events. While the two methods both capture some events, systematic reporting captures serious events, while voluntary reporting captures mainly insignificant and minor events.
OBJECTIVES:To identify factors affecting doctors' engagement with the Safer Patients Initiative (SPI).DESIGN:Qualitative interview study.SETTING:Four organisations participating in phase 1 of the SPI programme, from four different geographical locations in the UK.PARTICIPANTS:34 staff members, comprising senior executive/management leads involved in the SPI programme, the principal SPI programme coordinator and the operational leads in each of the SPI clinical work areas.MAIN OUTCOME MEASURES:Staff perceptions of issues affecting medical engagement with SPI, identified in the interviews.RESULTS:Qualitative analysis identified seven factors that were reported to affect medical engagement with the SPI programme: (1) Organisation Track Record in QSI, (2) Resource Availability & Allocation, (3) Perceptions of the purpose of SPI, (4) Evidence of Efficacy of Programme, (5) External Expertise, (6) Local Programme Champions and (7) Managers Involvement. Specific barriers and general enabling strategies were identified and described for each factor, based upon participants' experiences.CONCLUSIONS:Medical engagement is a complex technical, socio-political and motivational issue that is underpinned by a series of inter-related factors associated with the organisational context, the design of improvement programmes and how they are implemented and promoted. Healthcare organisations planning to embark on safety and quality-improvement programmes may benefit from systematically addressing the core themes identified by this study, in order to promote optimal medical engagement.
Objectives To study the extent and execution of redundant processes during inpatient transfers to Radiology, and their impact on errors during the transfer process; to explore the use of causal and reliability analyses for modelling error detection and redundancy in the transfer process; and to provide guidance on potential system improvements. Methods A prospective observational study at a metropolitan teaching hospital. 101 patient transfers to Radiology were observed over a 6-month period, and errors in patient transfer process were recorded. Fault Tree Analysis was used to model error paths and identify redundant steps. Reliability Analysis was used to quantify system reliability. Results 420 errors were noted, an average of four errors per transfer. No incidents of patient harm were recorded. Inadequate handover was the most common error (43.1%), followed by failure to perform patient identification checks (41.9%), patient inadequately prepared for transfer (7.4%), inadequate infection control precautions (2.9%), inadequate clinical escort (2.1%), inadequate transport vehicle (2.1%) and equipment failure (0.2%). Four redundant steps for communicating patients' infectious status were identified (reliability=0.07, 0.37, 0.26, 0.31). Collectively, these yielded a system reliability of 0.7. The low reliability of each individual step was due to its low rate of execution. Conclusions Analysis of the transfer process revealed a number of redundancies that safeguard against transfer errors. However, they were relatively ineffective in preventing errors, due to the poor compliance rate. Thus, the authors advocate increasing compliance to existing redundant processes as an improvement strategy, before investing resources on new processes.
OBJECTIVES:The authors conducted a randomised controlled trial of four pedagogical methods commonly used to deliver teamwork training and measured the effects of each method on the acquisition of student teamwork knowledge, skills, and attitudes.METHODS:The authors recruited 203 senior nursing students and 235 fourth-year medical students (total N = 438) from two major universities for a 1-day interdisciplinary teamwork training course. All participants received a didactic lecture and then were randomly assigned to one of four educational methods didactic (control), audience response didactic, role play and human patient simulation. Student performance was assessed for teamwork attitudes, knowledge and skills using: (a) a 36-item teamwork attitudes instrument (CHIRP), (b) a 12-item teamwork knowledge test, (c) a 10-item standardised patient (SP) evaluation of student teamwork skills performance and (d) a 20-item modification of items from the Mayo High Performance Teamwork Scale (MHPTS).RESULTS:All four cohorts demonstrated an improvement in attitudes (F(1,370) = 48.7, p = 0.001) and knowledge (F(1,353) = 87.3, p = 0.001) pre- to post-test. No educational modality appeared superior for attitude (F(3,370) = 0.325, p = 0.808) or knowledge (F(3,353) = 0.382, p = 0.766) acquisition. No modality demonstrated a significant change in teamwork skills (F(3,18) = 2.12, p = 0.134).CONCLUSIONS:Each of the four modalities demonstrated significantly improved teamwork knowledge and attitudes, but no modality was demonstrated to be superior. Institutions should feel free to utilise educational modalities, which are best supported by their resources to deliver interdisciplinary teamwork training.
Background Focusing on interprofessional relations in team performance to improve patient safety is an emerging priority in obstetrics. A review of the literature found little information on roles and teamwork in obstetric emergency training. Qualitative research was undertaken through a Clinical Simulation in Maternity programme which gives interprofessional rural clinicians the opportunity to learn collaboratively through simulated obstetric emergencies. This research aimed to determine how interprofessional simulation team training improved maternity emergency care and team performance.Method This research used thematic inductive analysis using data from in-depth interviews. In total 17 participants and four facilitators who took part in the Clinical Simulation in Maternity workshops were invited to participate in an interview 1-2 weeks postworkshop and then again 3-6 months later. Data were deidentified then coded manually and with the assistance of computer program NVivo 7 (QSR International).Findings Of the major themes identified, Collaboration in Teambuilding was separated into four subthemes (Personal Role Awareness, Interpositional Knowledge, Mutuality and Leadership).Conclusion This research highlights the significance of interprofessional training, particularly through simulation learning in a team where rural clinicians are able to learn more about each other and gain role clarity, leadership skills and mutuality in a safe environment.
