Implementing management innovations to improve safety of healthcare delivery is a critically important, yet often elusive, goal for healthcare organisations. Safety rounds, in which senior executives spend time on the frontlines of care, talking with staff and observing work, aim to improve safety of healthcare delivery by providing a systematic approach for engaging senior executives with the work system challenges faced by front-line staff and ensuring follow-up and accountability for addressing these challenges. They resemble ‘Management by Walking Around’, which originated at Hewlett-Packard1 and ‘gemba walks’, which are considered a key component of the Toyota Production System.2 However, descriptions of these precursor interventions emphasise engagement of senior executives with front-line workers and not follow-up and feedback about ideas generated through observation and discussion. Perhaps unlike in healthcare delivery, 3 follow up and feedback in technology and manufacturing companies can be assumed.

In this...

The years immediately following the widespread interest in patient safety1 and then healthcare quality2 saw considerable debate between pragmatically oriented improvers and research-oriented evaluators3–6 —or between ‘evangelists’ and ‘snails’ as one longtime observer characterised the two groups.7 Too often, enthusiastic improvers (‘evangelists’) relied on simple pre-post designs within a single context leading to erroneous claims of efficacy.8 In contrast, research-oriented investigators (‘snails’) and journals pushed for ever more rigorous designs including randomised trials, potentially at the cost of discouraging many improvers without this training and leading to slower development and deployment of effective interventions.9 10 Many clinicians, quality improvement (QI) experts and researchers are thus caught in a quandary: how best to evaluate a candidate QI intervention? How can we best balance the pragmatic needs of improvement—including the frequent need...

While methods broadly described as ‘ethnographic’ have been increasingly employed to research the organisation and delivery of healthcare,1–4 a single or widely accepted definition of ethnography has proved elusive and perhaps unnecessary.1 5 Nonetheless, even as authors publishing in this journal have adapted ethnographic approaches for the purpose of studying improving quality and safety in healthcare, they have often attempted to retain some of its anthropological ‘essence’.6 For instance, Dixon-Woods7 characterises ethnography in terms of its focus on observational methods, questioning of the taken for granted, description and analysis of routine behaviours in their natural settings, and use of the researcher’s own skill and judgement to both gather data and to interpret them drawing on social theory.

In a recent debate over use of the ethnographic label in this journal, Jowsey8 argued...

Background

There is a poorly understood relationship between Leadership WalkRounds (WR) and domains such as safety culture, employee engagement, burnout and work-life balance.

Methods

This cross-sectional survey study evaluated associations between receiving feedback about actions taken as a result of WR and healthcare worker assessments of patient safety culture, employee engagement, burnout and work-life balance, across 829 work settings.

Results

16 797 of 23 853 administered surveys were returned (70.4%). 5497 (32.7% of total) reported that they had participated in WR, and 4074 (24.3%) reported that they participated in WR with feedback. Work settings reporting more WR with feedback had substantially higher safety culture domain scores (first vs fourth quartile Cohen’s d range: 0.34–0.84; % increase range: 15–27) and significantly higher engagement scores for four of its six domains (first vs fourth quartile Cohen’s d range: 0.02–0.76; % increase range: 0.48–0.70).

Conclusion

This WR study of patient safety and organisational outcomes tested relationships with a comprehensive set of safety culture and engagement metrics in the largest sample of hospitals and respondents to date. Beyond measuring simply whether WRs occur, we examine WR with feedback, as WR being done well. We suggest that when WRs are conducted, acted on, and the results are fed back to those involved, the work setting is a better place to deliver and receive care as assessed across a broad range of metrics, including teamwork, safety, leadership, growth opportunities, participation in decision-making and the emotional exhaustion component of burnout. Whether WR with feedback is a manifestation of better norms, or a cause of these norms, is unknown, but the link is demonstrably potent.

Background

Although important in clinical care, reports of inappropriate peripherally inserted central catheter (PICC) use are growing.

Objective

To test whether implementation of the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) can improve PICC use and patient outcomes.

Design

Quasi-experimental, interrupted time series design at one study site with nine contemporaneous external controls.

Setting

Ten hospitals participating in a state-wide quality collaborative from 1 August 2014 to 31 July 2016.

Patients

963 hospitalised patients who received a PICC at the study site vs 6613 patients at nine control sites.

Intervention

A multimodal intervention (tool, training, electronic changes, education) derived from MAGIC.

Measurements

Appropriateness of PICC use and rates of PICC-associated complications. Segmented Poisson regression was used for analyses.

Results

Absolute rates of inappropriate PICC use decreased substantially at the study site versus controls (91.3% to 65.3% (–26.0%) vs 72.2% to 69.6% (–2.6%); P<0.001). After adjusting for underlying trends and patient characteristics, however, a marginally significant 13.8% decrease in inappropriate PICC use occurred at the study site (incidence rate ratio 0.86 (95% CI 0.74 to 0.99; P=0.048)); no change was observed at control sites. While the incidence of all PICC complications decreased to a greater extent at the study site, the absolute difference between controls and intervention was small (33.9% to 26.7% (–7.2%) vs 22.4% to 20.8% (–1.6%); P=0.036).

Limitations

Non-randomised design limits inference; the most effective component of the multimodal intervention is unknown; effects following implementation were modest.

Conclusions

In a multihospital quality improvement project, implementation of MAGIC improved PICC appropriateness and reduced complications to a modest extent. Given the size and resources required for this study, future work should consider cost-to-benefit ratio of similar approaches.

Background

In an obstetrical team, obstetricians, midwives and nurses work together in a dynamic and complex care setting. Different professional cultures can be a barrier for effective interprofessional collaboration. Although the different professional cultures in obstetrical care are well known, little is understood about discrepancies in mutual perceptions of collaboration. Similar perceptions of collaboration are important to ensure patient safety. We aimed to understand how different care professionals in an obstetrical team assess interprofessional collaboration in order to gain insight into the extent to which their perceptions are aligned.

Methods

This cross-sectional study was performed in the north-western region of the Netherlands. Care professionals from five hospitals and surrounding primary-care midwifery practices were surveyed. The respondents consisted of four groups of care professionals: obstetricians (n=74), hospital-based midwives known as clinical midwives (n=42), nurses (n=154) and primary-care midwives (n=109). The overall response rate was 80.8%. We used the Interprofessional Collaboration Measurement Scale (IPCMS) to assess perceived interprofessional collaboration. The IPCMS distinguishes three subscales: communication, accommodation and isolation. Data were analysed using non-parametrical tests.

Results

Overall, ratings of interprofessional collaboration were good. Obstetricians rated their collaboration with clinical midwives, nurses and primary-care midwives more positively than these three groups rated the collaboration with obstetricians. Discrepancies in mutual perceptions were most apparent in the isolation subscale, which is about sharing opinions, discussing new practices and respecting each other.

Conclusion

We found relevant discrepancies in mutual perceptions of collaboration in obstetrical care in the Netherlands. Obstetrical care is currently being reorganised to enable more integrated care, which will have consequences for interprofessional collaboration. The findings of this study indicate opportunities for improvement especially in terms of perceived isolation.

Background

The US government created five-star rating systems to evaluate hospital, nursing homes, home health agency and dialysis centre quality. The degree to which quality is a property of organisations versus geographical markets is unclear.

Objectives

To determine whether high-quality healthcare service sectors are clustered within US healthcare markets.

Design

Using data from the Centers for Medicare and Medicaid Services’ Hospital, Dialysis, Nursing Home and Home Health Compare databases, we calculated the mean star ratings of four healthcare sectors in 304 US hospital referral regions (HRRs). For each sector, we ranked HRRs into terciles by mean star rating. Within each HRR, we assessed concordance of tercile rank across sectors using a multirater kappa. Using t-tests, we compared characteristics of HRRs with three to four top-ranked sectors, one to two top-ranked sectors and zero top-ranked sectors.

Results

Six HRRs (2.0% of HRRs) had four top-ranked healthcare sectors, 38 (12.5%) had three top-ranked health sectors, 71 (23.4%) had two top-ranked sectors, 111 (36.5%) had one top-ranked sector and 78 (25.7%) HRRs had no top-ranked sectors. A multirater kappa across all sectors showed poor to slight agreement (K=0.055). Compared with HRRs with zero top-ranked sectors, those with three to four top-ranked sectors had higher median incomes, fewer black residents, lower mortality rates and were less impoverished. Results were similar for HRRs with one to two top-ranked sectors.

Conclusions

Few US healthcare markets exhibit high-quality performance across four distinct healthcare service sectors, suggesting that high-quality care in one sector may not be dependent on or improve care quality in other sectors. Policies that promote accountability for quality across sectors (eg, bundled payments and shared quality metrics) may be needed to systematically improve quality across sectors.

Background

Computerised prescriber order entry (CPOE) systems users often discontinue medications because the initial order was erroneous.

Objective

To elucidate error types by querying prescribers about their reasons for discontinuing outpatient medication orders that they had self-identified as erroneous.

Methods

During a nearly 3 year retrospective data collection period, we identified 57 972 drugs discontinued with the reason ‘Error (erroneous entry)." Because chart reviews revealed limited information about these errors, we prospectively studied consecutive, discontinued erroneous orders by querying prescribers in near-real-time to learn more about the erroneous orders.

Results

From January 2014 to April 2014, we prospectively emailed prescribers about outpatient drug orders that they had discontinued due to erroneous initial order entry. Of 2 50 806 medication orders in these 4 months, 1133 (0.45%) of these were discontinued due to error. From these 1133, we emailed 542 unique prescribers to ask about their reason(s) for discontinuing these mediation orders in error. We received 312 responses (58% response rate). We categorised these responses using a previously published taxonomy. The top reasons for these discontinued erroneous orders included: medication ordered for wrong patient (27.8%, n=60); wrong drug ordered (18.5%, n=40); and duplicate order placed (14.4%, n=31). Other common discontinued erroneous orders related to drug dosage and formulation (eg, extended release versus not). Oxycodone (3%) was the most frequent drug discontinued error.

Conclusion

Drugs are not infrequently discontinued ‘in error.’ Wrong patient and wrong drug errors constitute the leading types of erroneous prescriptions recognised and discontinued by prescribers. Data regarding erroneous medication entries represent an important source of intelligence about how CPOE systems are functioning and malfunctioning, providing important insights regarding areas for designing CPOE more safely in the future.

Objective

Medication voiding is a computerised provider order entry (CPOE)-based discontinuation mechanism that allows clinicians to identify erroneous medication orders. We investigated the accuracy of voiding as an indicator of clinician identification and interception of a medication ordering error, and investigated reasons and root contributors for medication ordering errors.

Method

Using voided orders identified with a void alert, we conducted interviews with ordering and voiding clinicians, followed by patient chart reviews. A structured coding framework was used to qualitatively analyse the reasons for medication ordering errors. We also compared clinician-CPOE-selected (at time of voiding), clinician-reported (interview) and chart review-based reasons for voiding.

Results

We conducted follow-up interviews on 101 voided orders. The positive predictive value (PPV) of voided orders that were medication ordering errors was 93.1% (95% CI 88.1% to 98.1%, n=94). Using chart review-based reasons as the gold standard, we found that clinician-CPOE-selected reasons were less reflective (PPV=70.2%, 95% CI 61.0% to 79.4%) than clinician-reported (interview) (PPV=86.1%, 95%CI 78.2% to 94.1%) reasons for medication ordering errors. Duplicate (n=44) and improperly composed (n=41) ordering errors were common, often caused by predefined order sets and data entry issues. A striking finding was the use of intentional violations as a mechanism to notify and seek ordering assistance from pharmacy service. Nearly half of the medication ordering errors were voided by pharmacists.

Discussion

We demonstrated that voided orders effectively captured medication ordering errors. The mismatch between clinician-CPOE-selected and the chart review-based reasons for error emphasises the need for developing standardised operational descriptions for medication ordering errors. Such standardisation can help in accurately identifying, tracking, managing and sharing erroneous orders and their root contributors between healthcare institutions, and with patient safety organisations.

Background

Pharmacists’ completion of medication reconciliation in the community after hospital discharge is intended to reduce harm due to prescribed or omitted medication and increase healthcare efficiency, but the effectiveness of this approach is not clear. We systematically review the literature to evaluate intervention effectiveness in terms of discrepancy identification and resolution, clinical relevance of resolved discrepancies and healthcare utilisation, including readmission rates, emergency department attendance and primary care workload.

Methods

This is a systematic literature review and meta-analysis of extracted data. Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, Allied and Complementary Medicine Database (AMED),Education Resources Information Center (ERIC), Scopus, NHS Evidence and the Cochrane databases were searched using a combination of medical subject heading terms and free-text search terms. Controlled studies evaluating pharmacist-led medication reconciliation in the community after hospital discharge were included. Study quality was appraised using the Critical Appraisal Skills Programme. Evidence was assessed through meta-analysis of readmission rates. Discrepancy identification rates, emergency department attendance and primary care workload were assessed narratively.

Results

Fourteen studies were included, comprising five randomised controlled trials, six cohort studies and three pre–post intervention studies. Twelve studies had a moderate or high risk of bias. Increased identification and resolution of discrepancies was demonstrated in the four studies where this was evaluated. Reduction in clinically relevant discrepancies was reported in two studies. Meta-analysis did not demonstrate a significant reduction in readmission rate. There was no consistent evidence of reduction in emergency department attendance or primary care workload.

Conclusions

Pharmacists can identify and resolve discrepancies when completing medication reconciliation after hospital discharge, but patient outcome or care workload improvements were not consistently seen. Future research should examine the clinical relevance of discrepancies and potential benefits on reducing healthcare team workload.

Background

The ability to capture the complexities of healthcare practices and the quick turnaround of findings make rapid ethnographies appealing to the healthcare sector, where changing organisational climates and priorities require actionable findings at strategic time points. Despite methodological advancement, there continue to be challenges in the implementation of rapid ethnographies concerning sampling, the interpretation of findings and management of field research. The purpose of this review was to explore the benefits and challenges of using rapid ethnographies to inform healthcare organisation and delivery and identify areas that require improvement.

Methods

This was a systematic review of the literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We used the Mixed Methods Appraisal Tool to assess the quality of the articles. We developed the search strategy using the Population, Intervention, Comparison, Outcomes, Settingframework and searched for peer-reviewed articles in MEDLINE, CINAHL PLUS, Web of Science and ProQuest Central. We included articles that reported findings from rapid ethnographies in healthcare contexts or addressing issues related to health service use.

Results

26 articles were included in the review. We found an increase in the use of rapid ethnographies in the last 2years. We found variability in terminology and developed a typology to clarify conceptual differences. The studies generated findings that could be used to inform policy and practice. The main limitations of the studies were: the poor quality of reporting of study designs, mainly data analysis methods, and lack of reflexivity.

Conclusions

Rapid ethnographies have the potential to generate findings that can inform changes in healthcare practices in a timely manner, but greater attention needs to be paid to the reflexive interpretation of findings and the description of research methods.

Trial registration number

CRD42017065874.

Martin Marshall and colleagues1 take themselves to task for the suboptimal design of a complex (multicomponent) intervention to improve safety of services for people in care homes. The authors make much of the complexity of the intervention—service interventions are ‘not like a pill’. Interventions must be adapted—when first promulgated the intervention in question had nine components, and this inflated to 15 over the course of the project. Contrast all of these with a financial incentive promulgated by the Specialist Services Commissioning authority for the West Midlands, England. Hospitals were simply given a financial incentive to promote a switch from facility to home haemodialysis.2

So here we have accounts of what appear to be two very different types of interventions; Marshall’s intervention encapsulates 15 components, while the commissioning agent’s intervention was of one component only. One might think that Marshall’s intervention was complex and the commissioning agent’s...

Pressure injuries are problematic to health systems throughout the world, significantly harming over 7 million patients and adding extraordinary costs. The USA, for instance, experiences more than 2.5 million pressure injury cases per year which cause over 60 000 deaths—that is more than car accident fatalities in the USA—and cost the health system at least $9–$11 billion.1 The UK is no less affected by 700 000 cases per year that result in 27 000 deaths and cost the National Health Service (NHS) an estimated £1.4–£2.1 billion.2

Despite there being no reason to expect major differences in the presentation of pressure injuries between the two countries, the UK appears mainly to have a problem with chronic pressure ulcers, whereas the USA appears to have an increasing burden of acute pressure ulcers.3 4 The UK NHS reports chronic wounds accounting for 78% of the NHS spending on wound treatments.

Assuring public safety after widespread adoption of medical devices is critically important, and has been identified as a priority by the Food and Drug Administration (FDA).1 Growing public concern regarding postmarket safety of medical devices stems in part from an increasing recognition that medical device failure, although infrequent, may lead to injury. Regulatory agencies, such as FDA, are faced with the competing pressures of ensuring patient safety while simultaneously improving the efficiency of medical device approval. Unfortunately, premarket medical device approval studies are frequently limited by small sample size, restricted patient and provider populations, and inadequate duration of follow-up.2 3 Therefore, strengthening approaches of postmarket safety evaluation are increasingly important.

The FDA strategy for postmarket safety evaluation has relied extensively on reporting of adverse events by physicians, patients and device manufacturers through the Medical Device Reporting system. It has become increasingly apparent that, despite...

Internationally, primary care is under pressure. In 10 developed nations surveyed for the 2015 Commonwealth report, primary care physicians reported their struggle to find ways to care for ageing populations with complex healthcare needs.1 Practice consultation rates, average consultation duration and total patient-facing clinical workload have increased substantially in primary care in recent years.2 Increases in demand have not been matched by growth in either funding or in workforce: in the UK alone, the shortage of general practitioners (GPs) is expected to worsen from 3300 in 2015 to 8000 by 2020. Over and above rising demand, factors such as advances in technology, the shifting workload from secondary to primary care, and patients’ growing health and social care needs (including more complicated drug regimens and challenging national clinical standards) have all added to complexity.3

Much discussion has focused on how to increase the supply...

Contemporary health policies frequently invoke notions of ‘culture’ and ‘cultural change’ as levers for achieving performance improvement and good-quality healthcare.1 But it has remained unclear whether talk of culture is largely empty rhetoric or whether framing healthcare organisations in ‘cultural’ terms offers useful insights that might improve organisational processes and outcomes of care. When considering the role of organisational culture in facilitating high-quality care and improved outcomes, a first important step is to explain what is meant by organisational culture, and then consider the evidence that organisational culture can be purposively managed and form part of efforts to improve quality and clinical performance in healthcare delivery organisations.

A recent systematic review found a consistent association between positive organisational and workplace cultures and beneficial clinical outcomes, including reduced mortality rates across a variety of health settings.2 Most ‘included’ studies in the review consisted of observational and...

Background

Hospital-acquired pressure injuries (HAPIs) are publicly reported in the USA and used to adjust Medicare payment to acute inpatient facilities. Current methods used to identify HAPIs in administrative claims rely on hospital-reported present-on-admission (POA) data instead of prior patient health information.

Objective

To study the reliability of claims data for HAPIs and pressure injury (PI) stage by evaluating diagnostic coding agreement across interfacility transfers.

Methods

Using the 2012 100% Medicare Provider and Analysis Review file, we identified all fee-for-service acute inpatient discharge records with a PI diagnosis among Medicare patients 65 years and older. We then identified additional facility claims (eg, acute inpatient, long-stay inpatient or skilled nursing facility) belonging to the same patient who had either (1) admission within 1day of hospital discharge or (2) discharge within 1day of hospital admission. Multivariable logistic regression and stratified kappa statistics were used to measure coding agreement between transferring and receiving facilities in the presence or absence of a PI diagnosis at the time of patient transfer and PI stage category (early vs advanced).

Results

In our comparison of claims data between transferring and receiving facilities, we observed poor agreement in the presence or absence of a PI diagnosis at the time of transfer (36.3%, kappa=0.03) and poor agreement in PI stage category (74.3%, kappa=0.17). Among transfers with a POA PI reported by the receiving hospital, only 34.0% had a PI documented at the prior transferring facility.

Conclusions

The observed discordance in PI documentation and staging between transferring and receiving facilities may indicate inaccuracy of HAPI identification in claims data. Future research should evaluate the accuracy of hospital-reported POA data and its impact on PI quality measurement.

Background

Postmarket surveillance of medical devices is reliant on physician reporting of adverse medical device events (AMDEs). Little is known about factors that influence whether and how physicians report AMDEs, an essential step in developing behaviour change interventions. This study explored factors that influence AMDE reporting.

Methods

Qualitative interviews were conducted with physicians who differed by specialties that implant cardiovascular and orthopaedic devices prone to AMDEs, geography and years in practice. Participants were asked if and how they reported AMDEs, and the influencing factors. Themes were identified inductively using constant comparative technique, and reviewed and discussed by the research team on four occasions.

Results

Twenty-two physicians of varying specialty, region, organisation and career stage perceived AMDE reporting as unnecessary, not possible or futile due to multiple factors. Physicians viewed AMDEs as an expected part of practice that they could manage by switching to different devices or developing work-around strategies for problematic devices. Physician beliefs and behaviour were reinforced by limited healthcare system capacity and industry responsiveness. The healthcare system lacked processes and infrastructure to detect, capture, share and act on information about AMDEs, and constrained device choice through purchasing contracts. The device industry did not respond to reports of AMDEs from physicians or improve their products based on such reports. As a result, participants said they used devices that were less than ideal for a given patient, leading to suboptimal patient outcomes.

Conclusions

There may be little point in solely educating or incentivising individual physicians to report AMDEs unless environmental conditions are conducive to doing so. Future research should explore policies that govern AMDEs and investigate how to design and implement postmarket surveillance systems.

Background

Prescribing is a high-volume primary care routine where both speed and attention to detail are required. One approach to examining how organisations approach quality and safety in the face of high workloads is Hollnagel’s Efficiency and Thoroughness Trade-Off (ETTO). Hollnagel argues that safety is aligned with thoroughness and that a choice is required between efficiency and thoroughness as it is not usually possible to maximise both. This study aimed to ethnographically examine the efficiency and thoroughness trade-offs made by different UK general practices in the achievement of prescribing safety.

Methods

Non-participant observation was conducted of prescribing routines across eight purposively sampled UK general practices. Sixty-two semistructured interviews were also conducted with key practice staff alongside the analysis of relevant practice documents.

Results

The eight practices in this study adopted different context-specific approaches to safely handling prescription requests by variably prioritising speed of processing by receptionists (efficiency) or general practitioner (GP) clinical judgement (thoroughness). While it was not possible to maximise both at the same time, practices situated themselves at various points on an efficiency-thoroughness spectrum where one approach was prioritised at particular stages of the routine. Both approaches carried strengths and risks, with thoroughness-focused approaches considered safer but more challenging to implement in practice due to GP workload issues. Most practices adopting efficiency-focused approaches did so out of necessity as a result of their high workload due to their patient population (eg, older, socioeconomically deprived).

Conclusions

Hollnagel’s ETTO presents a useful way for healthcare organisations to optimise their own high-volume processes through reflection on where they currently prioritise efficiency and thoroughness, the stages that are particularly risky and improved ways of balancing competing priorities.

Background

Hospital organisational culture affects patient outcomes including mortality rates for patients with acute myocardial infarction; however, little is known about whether and how culture can be positively influenced.

Methods

This is a 2-year, mixed-methods interventional study in 10 US hospitals to foster improvements in five domains of organisational culture: (1) learning environment, (2) senior management support, (3) psychological safety, (4) commitment to the organisation and (5) time for improvement. Outcomes were change in culture, uptake of five strategies associated with lower risk-standardised mortality rates (RSMR) and RSMR. Measures included a validated survey at baseline and at 12 and 24 months (n=223; average response rate 88%); in-depth interviews (n=393 interviews with 197 staff); and RSMR data from the Centers for Medicare and Medicaid Services.

Results

We observed significant changes (p<0.05) in culture between baseline and 24 months in the full sample, particularly in learning environment (p<0.001) and senior management support (p<0.001). Qualitative data indicated substantial shifts in these domains as well as psychological safety. Six of the 10 hospitals achieved substantial improvements in culture, and four made less progress. The use of evidence-based strategies also increased significantly (per hospital average of 2.4 strategies at baseline to 3.9 strategies at 24 months; p<0.05). The six hospitals that demonstrated substantial shifts in culture also experienced significantly greater reductions in RSMR than the four hospitals that did not shift culture (reduced RSMR by 1.07 percentage points vs 0.23 percentage points; p=0.03) between 2011–2014 and 2012–2015.

Conclusions

Investing in strategies to foster an organisational culture that supports high performance may help hospitals in their efforts to improve clinical outcomes.