Medical education and patient care are inextricably linked. At this time, with the limitations of simulation training and our continued dependence on educated physicians for clinical decision-making, one domain cannot exist without the other. The involvement of medical trainees in patient care means it is vital that the impact of changes to medical training programmes on patient outcomes are assessed with well-designed studies. The study, "National improvements in resident physician-reported patient safety after limiting first-year resident physicians’ extended duration work shifts,"1 by Weaver and colleagues published in this month’s issue of BMJ Quality and Safety signals the need for a robust discussion of education policy research within the field of medicine.
Before specifically addressing the approach used by Weaver et al,1 a review of the complexities involved in studying the impact of medical education policy is warranted.2 The field of ‘education outcomes research’...
Low-value care refers to tests or treatments for which there is little evidence of benefit or more harm than benefit, which can result in poor patient outcomes such as unwarranted secondary tests or adverse events. In this context, inefficient use of scarce healthcare resources threatens the sustainability of healthcare systems and low-value care is an obvious target. About 25%–30% of all care has been estimated to be of low value in countries such as Australia, Canada, Spain, Brazil and the USA, and this estimate rises to 80% for certain procedures.1 There is increasing interest to identify areas of low-value care based on available evidence, guidelines and expert opinion,2 including initiatives such as Choosing Wisely3 and the British Medical Journal’s Too Much Medicine campaign.4 These campaigns aim to reduce or stop low-value services (i.e., de-implement) from the ‘bottom up’, at micro or...
Core to the role of a hospital board is establishing organisational strategy and multi-year priorities, ensuring processes are in place for risk prevention and mitigation, and overseeing progress on strategic outcomes relevant to multiple quality domains. This role is distinct from that of the hospital management team (comprised of managers and clinical and operational leaders) that is responsible for daily operations and implementing the hospital’s strategic plan.1 While senior executives such as Chief Executive Officers may sit on both boards and management teams in some countries (such as the UK and Canada), the roles of boards and management teams differ. For example, boards focus on long-term strategic planning, while management focuses on day-to-day operations. To support these different roles, hospital boards and management teams both need access to data in graphic formats that help to differentiate random variation from significant changes, although required elements may differ. Hospital...
There is a growing body of research which evidences that lesbian, gay, bisexual and/or transgender (LGBT+) people experience significant health inequalities.1 We know that LGBT+ individuals may have encountered accumulative experiences of stigma and discrimination across their lives, which can have a negative impact on their health and can even have some bearing on their life expectancy.2 The fear of stigma and discrimination can also impact on LGBT+ people accessing timely healthcare. Furthermore, there are barriers in our healthcare systems that increase these health inequities.3–5
Braybrook’s paper6 in this issue of BMJ Quality & Safety makes an important contribution to this work. It adds to a growing literature that addresses the experiences of LGBT+ people (and their significant others) at...
Health systems worldwide are focused on improving patient and population healthcare outcomes. Data are increasingly leveraged to support these aims, including clinical performance feedback (CPF) initiatives that provide clinicians with data on how often their patients are receiving evidence-based care compared with a specific improvement goal, which may reflect a standardised target or how they perform in comparison to their peers.1 2 Unfortunately, engagement with and impact of providing data is variable. We need to tailor data to the nature of its clinician recipients in the same way we tailor the nature of care to the individual patient. This will require continued investment in producing and analysing data and a better understanding of the clinicians whose behaviours we are trying to optimise. CPF initiatives that truly help clinicians achieve their goals in this regard are more likely to be well received. Imagine a...
The Accreditation Council for Graduate Medical Education (ACGME) enacted a policy in 2011 that restricted first-year resident physicians in the USA to work no more than 16 consecutive hours. This was rescinded in 2017.Methods
We conducted a nationwide prospective cohort study of resident physicians for 5 academic years (2002–2007) before and for 3 academic years (2014–2017) after implementation of the 16 hours 2011 ACGME work-hour limit. Our analyses compare trends in resident physician-reported medical errors between the two cohorts to evaluate the impact of this policy change.Results
14 796 residents provided data describing 78 101 months of direct patient care. After adjustment for potential confounders, the work-hour policy was associated with a 32% reduced risk of resident physician-reported significant medical errors (rate ratio (RR) 0.68; 95% CI 0.64 to 0.72), a 34% reduced risk of reported preventable adverse events (RR 0.66; 95% CI 0.59 to 0.74) and a 63% reduced risk of reported medical errors resulting in patient death (RR 0.37; 95% CI 0.28 to 0.49).Conclusions
These findings have broad relevance for those who work in and receive care from academic hospitals in the USA. The decision to lift this work hour policy in 2017 may expose patients to preventable harm.
The NHS England evidence-based interventions programme (EBI), launched in April 2019, is a novel nationally led initiative to encourage disinvestment in low value care.Method
We sought to evaluate the effectiveness of this policy by using a difference-in-difference approach to compare changes in volume between January 2016 and February 2020 in a treatment group of low value procedures against a control group unaffected by the EBI programme during our period of analysis but subsequently identified as candidates for disinvestment.Results
We found only small differences between the treatment and control group after implementation, with reductions in volumes in the treatment group 0.10% (95% CI 0.09% to 0.11%) smaller than in the control group (equivalent to 16 low value procedures per month). During the month of implementation, reductions in volumes in the treatment group were 0.05% (95% CI 0.03% to 0.06%) smaller than in the control group (equivalent to 7 low value procedures). Using triple difference estimators, we found that reductions in volumes were 0.35% (95% CI 0.26% to 0.44%) larger in NHS hospitals than independent sector providers (equivalent to 47 low value procedures per month). We found no significant differences between clinical commissioning groups that did or did not volunteer to be part of a demonstrator community to trial EBI guidance, but found reductions in volume were 0.06% (95% CI 0.04% to 0.08%) larger in clinical commissioning groups that posted a deficit in the financial year 2018/19 before implementation (equivalent to 4 low value procedures per month).Conclusions
Our analysis shows that the EBI programme did not accelerate disinvestment for procedures under its remit during our period of analysis. However, we find that financial and organisational factors may have had some influence on the degree of responsiveness to the EBI programme.
Statistical process control charts (SPCs) distinguish signal from noise in quality and safety metrics and thus enable resources to be targeted towards the most suitable actions for improving processes and outcomes. Nevertheless, according to a recent study, SPCs are not widely used by hospital boards in England. To address this, an educational training initiative with training sessions lasting less than one and a half days was established to increase uptake of SPCs in board papers. This research evaluated the impact of the training sessions on the inclusion of SPCs in hospital board papers in England.Methods
We used a non-randomised controlled before and after design. Use of SPCs was examined in 40 publicly available board papers across 20 hospitals; 10 intervention hospitals and 10 control hospitals matched using hospital characteristics and time-period. Zero-inflated negative binomial regression models and t-tests compared changes in usage by means of a difference in difference approach.Results
Across the 40 board papers in our sample, we found 6287 charts. Control hospitals had 9/1585 (0.6%) SPCs before the intervention period and 23/1900 (1.2%) after the intervention period, whereas intervention hospitals increased from 89/1235 (7%) before to 328/1567 (21%) after the intervention period; a relative risk ratio of 9 (95% CI 3 to 32). The absolute difference in use of SPCs was 17% (95% CI 6% to 27%) in favour of the intervention group.Conclusions
The results suggest that a scalable educational training initiative to improve use of SPCs within organisations can be effective. Future research could aim to overcome the limitations of observational research with an experimental design or seek to better understand mechanisms, decision-making and patient outcomes.
Healthcare organisations have legal and ethical duties to reduce inequalities in access to healthcare services and related outcomes. However, lesbian, gay, bisexual and/or transgender (LGBT+) people continue to experience and anticipate discrimination in health and social care. Skilled communication is vital for quality person-centred care, but there is inconsistent provision of evidence-based clinician education on health needs and experiences of LGBT+ people to support this. This study aimed to identify key stakeholders’ experiences, preferences and best practices for communication regarding sexual orientation, gender identity and gender history in order to reduce inequalities in healthcare.Methods
Semistructured qualitative interviews with LGBT+ patients with serious illness, significant others and clinicians, recruited via UK-wide LGBT+ groups, two hospitals and one hospice in England. We analysed the interview data using reflexive thematic analysis.Results
74 stakeholders participated: 34 LGBT+ patients with serious illness, 13 significant others and 27 multiprofessional clinicians. Participants described key communication strategies to promote inclusive practice across three domains: (1) ‘Creating positive first impressions and building rapport’ were central to relationship building and enacted through routine use of inclusive language, avoiding potentially negative non-verbal signals and echoing terminology used by patients and caregivers; (2) ‘Enhancing care by actively exploring and explaining the relevance of sexual orientation and gender identity’, participants described the benefits of clinicians initiating these discussions, pursuing topics guided by the patient’s response or expressed preferences for disclosure. Active involvement of significant others was encouraged to demonstrate recognition of the relationship; these individual level actions are underpinned by a foundation of (3) ‘visible and consistent LGBT+ inclusiveness in care systems’. Although participants expressed hesitance talking about LGBT+ identities with individuals from some sociocultural and religious backgrounds, there was widespread support for institutions to adopt a standardised, LGBT+ inclusive, visibly supportive approach.Conclusions
Person-centred care can be enhanced by incorporating discussions about sexual orientation and gender identity into routine clinical practice. Inclusive language and sensitive exploration of relationships and identities are core activities. Institutions need to support clinicians through provision of adequate training, resources, inclusive monitoring systems, policies and structures. Ten inclusive communication recommendations are made based on the data.