Quality and Safety in Health Care Journal

Inpatient bedspacing: could a common response to hospital crowding cause increased patient mortality?

Emergency department (ED) overcrowding results in patient and provider dissatisfaction, poorer quality of care, increased healthcare costs, and even increased mortality in some studies.1–4 In response to this evidence, many hospitals have instituted full capacity protocols in which patients in the ED who are admitted but waiting for a bed on the home ward of the admitting service are sent to the first available inpatient bed (or even inpatient hallway) even if it is off-service—a practice known in the UK as boarding or medical outliers,5 6 and in other countries as bedspacing.

Why might bedspacing matter? Caring for these patients may seem to present only the minor inconvenience to physicians of making short trips off their home ward to visit the floor of some other clinical service. The potential problem arises with undermining multidisciplinary care. While physician...

Unpacking quality indicators: how much do they reflect differences in the quality of care?

Just over 50 years ago, Avedis Donabedian published his seminal paper, which sought to define and specify the ‘quality of health care’, articulating the now paradigmatic triad of structure, process and outcome for measuring healthcare quality.1 In recent years, we have seen the rapid expansion of increasingly inexpensive information technology capability and capacity, facilitating the collection and analysis of large healthcare data sets. These technological advances fuel the current proliferation of performance measurement in healthcare.2 Increasingly, in an effort to improve care, many cancer health systems, including those in England,3 the USA4 and Canada,5 6 are publicly reporting performance indicators, generally derived from these large data sets. Not surprisingly, differences in prevention, early detection and/or treatment of cancer are often used to explain the observed differences in performance across jurisdictions.6–9

Given the...

Putting rising emergency hospital admissions for children into perspective: how do international comparisons help?

All parents want the same for their child

Emergency department (ED) visits and hospital admissions are often monitored to get an understanding of urgent hospital activity, but are also used as an indicator of the accessibility and quality of services outside the hospital. The factors determining whether or not a family will seek care in the ED and be admitted are complex (figure 1), and this picture becomes even more complex when comparing between areas or countries. One thing that can be counted on, however, is that regardless of country, nationality, health system or personal preferences, all parents are likely to want the same for their child: for them to receive the best care possible—care that is easily accessible, safe, effective, most appropriate for their needs and provided in a caring environment.

When a parent becomes concerned about their child’s health, they need reassurance and advice...

Mortality of hospitalised internal medicine patients bedspaced to non-internal medicine inpatient units: retrospective cohort study


To compare inhospital mortality of general internal medicine (GIM) patients bedspaced to off-service wards with GIM inpatients admitted to assigned GIM wards.


A retrospective cohort study of consecutive GIM admissions between 1 January 2015 and 1 January 2016 was conducted at a large tertiary care hospital in Canada.

Inhospital mortality was compared between patients admitted to off-service wards (bedspaced) and assigned GIM wards using a Cox proportional hazards model and a competing risk model. Sensitivity analyses included propensity score and pair matching based on GIM service team, workload, demographics, time of admission, reasons for admission and comorbidities.


Among 3243 consecutive GIM admissions, more than a third (1125, 35%) were bedspaced to off-service wards with the rest (2118, 65%) admitted to assigned GIM wards. In hospital, 176 (5%) patients died: 88/1125 (8%) bedspaced patients and 88/2118 (4%) assigned GIM ward patients. Compared with assigned GIM wards patients, bedspaced patients had an HR of 3.42 (95% CI 2.23 to 5.26; P<0.0001) for inhospital mortality at admission, which then decreased by HR of 0.97 (95% CI 0.94 to 0.99; P=0.0133) per day in hospital. Competing risk models and sensitivity analyses using propensity scores and pair matching yielded similar results.


Bedspaced patients had significantly higher inhospital mortality than patients admitted to assigned GIM wards. The risk was highest at admission and subsequently declined. The results of this single centre study may not be generalisable to other hospitals and may be influenced by residual confounding. Despite these limitations, the relationship between bedspacing and patient outcomes requires investigation at other institutions to determine if this common practice represents a modifiable patient safety indicator.

Variation and statistical reliability of publicly reported primary care diagnostic activity indicators for cancer: a cross-sectional ecological study of routine data


Recent public reporting initiatives in England highlight general practice variation in indicators of diagnostic activity related to cancer. We aimed to quantify the size and sources of variation and the reliability of practice-level estimates of such indicators, to better inform how this information is interpreted and used for quality improvement purposes.


Ecological cross-sectional study.


English primary care.


All general practices in England with at least 1000 patients.

Main outcome measures

Sixteen diagnostic activity indicators from the Cancer Services Public Health Profiles.


Mixed-effects logistic and Poisson regression showed that substantial proportions of the observed variance in practice scores reflected chance, variably so for different indicators (between 7% and 85%). However, after accounting for the role of chance, there remained substantial variation between practices (typically up to twofold variation between the 75th and 25th centiles of practice scores, and up to fourfold variation between the 90th and 10th centiles). The age and sex profile of practice populations explained some of this variation, by different amounts across indicators. Generally, the reliability of diagnostic process indicators relating to broader populations of patients most of whom do not have cancer (eg, rate of endoscopic investigations, or urgent referrals for suspected cancer (also known as ‘two week wait referrals’)) was high (≥0.80) or very high (≥0.90). In contrast, the reliability of diagnostic outcome indicators relating to incident cancer cases (eg, per cent of all cancer cases detected after an emergency presentation) ranged from 0.24 to 0.54, which is well below recommended thresholds (≥0.70).


Use of indicators of diagnostic activity in individual general practices should principally focus on process indicators which have adequate or high reliability and not outcome indicators which are unreliable at practice level.

International comparison of emergency hospital use for infants: data linkage cohort study in Canada and England


To compare emergency hospital use for infants in Ontario (Canada) and England.


We conducted a population-based data linkage study in infants born ≥34 weeks’ gestation between 2010 and 2013 in Ontario (n=253 930) and England (n=1 361 128). Outcomes within 12 months of postnatal discharge were captured in hospital records. The primary outcome was all-cause unplanned admissions. Secondary outcomes included emergency department (ED) visits, any unplanned hospital contact (either ED or admission) and mortality. Multivariable regression was used to evaluate risk factors for infant admission.


The percentage of infants with ≥1 unplanned admission was substantially lower in Ontario (7.9% vs 19.6% in England) while the percentage attending ED but not admitted was higher (39.8% vs 29.9% in England). The percentage of infants with any unplanned hospital contact was similar between countries (42.9% in Ontario, 41.6% in England) as was mortality (0.05% in Ontario, 0.06% in England). Infants attending ED were less likely to be admitted in Ontario (7.3% vs 26.2%), but those who were admitted were more likely to stay for ≥1 night (94.0% vs 55.2%). The strongest risk factors for admission were completed weeks of gestation (adjusted OR for 34–36 weeks vs 39+ weeks: 2.44; 95% CI 2.29 to 2.61 in Ontario and 1.66; 95% CI 1.62 to 1.70 in England) and young maternal age.


Children attending ED in England were much more likely to be admitted than those in Ontario. The tendency towards more frequent, shorter admissions in England could be due to more pressure to admit within waiting time targets, or less availability of paediatric expertise in ED. Further evaluations should consider where best to focus resources, including in-hospital, primary care and paediatric care in the community.

Enhancing problem list documentation in electronic health records using two methods: the example of prior splenectomy


Quality improvement professionals often choose between patient-specific interventions, like clinical decision support (CDS), and population-based interventions, like registries or care management. In this paper, we explore the synergy of these two strategies, targeting the problem of procedure documentation for patients with a history of splenectomy.


We developed a population health documentation (PHD) intervention and a CDS intervention to improve splenectomy documentation within our electronic health record. Rates of splenectomy documentation were collected before and after the implementation of both interventions to assess their impact on the rate of procedure documentation.


Both the PHD and CDS interventions led to statistically significant (p<0.001) increases in the baseline rate of splenectomy documentation of 27.4 documentations per month. During the PHD intervention, 444.7 splenectomies were documented per month, while 40.8 splenectomies per month were documented during the CDS intervention.


Both approaches were successful, with the PHD intervention leading to a larger number of incremental procedure documentations, in batches, and the CDS intervention augmenting procedure documentation on an ongoing basis. Our results suggest that population health and CDS strategies complement each other and, where possible, should be used in conjunction.


PHD and CDS strategies may best be used in conjunction to create a symbiotic relationship in which current problem and procedure documentation gaps are closed using PHD strategies, while new gaps are prevented through ongoing CDS interventions

Is quality important to our patients? The relationship between surgical outcomes and patient satisfaction


With greater transparency in health system reporting and increased reliance on patient-centred outcomes, patient satisfaction has become a priority in delivering quality care. We sought to explore the relationship between patient satisfaction and short-term outcomes in patients undergoing general surgical procedures.


Satisfaction surveys were distributed to patients following discharge from the general surgery service at an academic hospital between June 2012 and March 2015. Short-term clinical outcomes were obtained from the American College of Surgeons National Surgical Quality Improvement Program database. Patients rated their level of satisfaction on a 5-point Likert scale, and ordered logistic regression model was used to determine predictors of high patient satisfaction.


757 patient satisfaction surveys were completed. The mean age of patients surveyed was 52.2 years; 60.0% of patients were female. The majority of patients underwent a laparoscopic procedure (85.9%) and were admitted as inpatients following surgery (72%). 91.5% of patients rated satisfaction of 4–5, and 95.0% said they would recommend the service. The odds of overall satisfaction were lower in patients who had complications (OR: 0.52, 95% CI 0.31 to 0.87) and 30-day readmission (OR: 0.35, 95% CI 0.17 to 0.70). Having elective surgery was associated with higher odds of satisfaction (OR: 1.62, 95% CI 1.07 to 2.47).


We found a significant association between patient satisfaction and both 30-day readmission and the occurrence of postoperative surgical complications. Given this association, further study is warranted to evaluate patient satisfaction as a healthcare quality indicator.

Malpractice claims related to diagnostic errors in the hospital


Little is known about the incidence or significance of diagnostic error in the inpatient setting. We used a malpractice claims database to examine incidence, predictors and consequences of diagnosis-related paid malpractice claims in hospitalised patients.


The US National Practitioner Database was used to identify paid malpractice claims occurring between 1 January 1999 and 31 December 2011. Patient and provider characteristics associated with paid claims were analysed using descriptive statistics. Differences between diagnosis-related paid claims and other paid claim types (eg, surgical, anaesthesia, medication) were assessed using Wilcoxon rank-sum and 2 tests. Multivariable logistic regression was used to identify patient and provider factors associated with diagnosis-related paid claims. Trends for incidence of diagnosis-related paid claims and median annual payment were assessed using the Cochran-Armitage and non-parametric trend test.


13 682 of 62 966 paid malpractice claims (22%) were diagnosis-related. Compared with other paid claim types, characteristics significantly associated with diagnosis-related paid claims were as follows: male patients, patient aged >50 years, provider aged <50 years and providers in the northeast region. Compared with other paid claim types, diagnosis-related paid claims were associated with 1.83 times more risk of disability (95% CI 1.75 to 1.91; p<0.001) and 2.33 times more risk of death (95% CI 2.23 to 2.43; p<0.001) than minor injury, after adjusting for patient and provider characteristics. Inpatient diagnostic error accounted for $5.7 billion in payments over the study period, and median diagnosis-related payments increased at a rate disproportionate to other types.


Inpatient diagnosis-related malpractice payments are common and more often associated with disability and death than other claim types. Research focused on understanding and mitigating diagnostic errors in hospital settings is necessary.

Value of small sample sizes in rapid-cycle quality improvement projects 2: assessing fidelity of implementation for improvement interventions


Fidelity is the degree to which a change is implemented as intended. Improvement project teams should measure fidelity, because if the change is not implemented, nothing will change. However, measurement resources are usually limited, especially in the early stages of implementation. A frequent problem in quality improvement is that people waste time collecting too much data. A previous paper1 showed how to demonstrate local gaps in care with very small samples of 5–10 patients. In evaluative clinical trials, the goal is to detect small differences between groups with precise estimates of these differences. By contrast, local quality improvement is often asking whether local performance meets a specific standard, such as 80% compliance with a guideline. If local performance is poor, small samples of 5–10 patients may be large enough to demonstrate a gap in care. In this paper, our goal is to offer some general...

Utilizing a transfer of care bundle to reduce unplanned readmissions to the cardiac intensive care unit


Hospital-based intensive care is known to be a significant driver of healthcare costs. In the USA, intensive care unit (ICU) care accounted for 13% of all hospital costs in 2005.1 One aspect of ICU care that has been found to be both a driver of cost and a measure of quality is ICU readmissions.1 As a result, readmission to the ICU within a single hospitalisation is now viewed by payers as a potential preventable complication, and payers are beginning to propose denial of charges associated with these episodes of care given the impact on length of stay (LOS) and hospital charges.2 Examples from the literature include data from an adult medicine multicentre database enquiry that demonstrated that patients who were readmitted to an ICU have a 2.5-fold increase in hospital LOS compared with patients who were not readmitted.3 Furthermore, Magruder...

Effects of efforts to optimise morbidity and mortality rounds to serve contemporary quality improvement and educational goals: a systematic review


The quality and safety movement has reinvigorated interest in optimising morbidity and mortality (M&M) rounds. We performed a systematic review to identify effective means of updating M&M rounds to (1) identify and address quality and safety issues, and (2) address contemporary educational goals.


Relevant databases (Medline, Embase, PubMed, Education Resource Information Centre, Cumulative Index to Nursing and Allied Health Literature, Healthstar, and Global Health) were searched to identify primary sources. Studies were included if they (1) investigated an intervention applied to M&M rounds, (2) reported outcomes relevant to the identification of quality and safety issues, or educational outcomes relevant to quality improvement (QI), patient safety or general medical education and (3) included a control group. Study quality was assessed using the Medical Education Research Study Quality Instrument and Newcastle-Ottawa Scale-Education instruments. Given the heterogeneity of interventions and outcome measures, results were analysed thematically.


The final analysis included 19 studies. We identified multiple effective strategies (updating objectives, standardising elements of rounds and attaching rounds to a formal quality committee) to optimise M&M rounds for a QI/safety purpose. These efforts were associated with successful integration of quality and safety content into rounds, and increased implementation of QI interventions. Consistent effects on educational outcomes were difficult to identify, likely due to the use of methodologies ill-fitted for educational research.


These results are encouraging for those seeking to optimise the quality and safety mission of M&M rounds. However, the inability to identify consistent educational effects suggests the investigation of M&M rounds could benefit from additional methodologies (qualitative, mixed methods) in order to understand the complex mechanisms driving learning at M&M rounds.

Balancing the skills: the need for an improvement pyramid

Improvements in health services require a range of technical skills, but like all complex organisational tasks they also rely on the personal skills and attitudes of the staff carrying out the changes. That much is axiomatic.1 2 3 Less certain, but surely potentially helpful to front-line staff undertaking improvement initiatives, is ascertaining just what might be the right sets of skills needed for different kinds of improvement tasks in varying circumstances.4 5 6

Useful insights into the ways in which a range of organisational circumstances demand such skills were exposed when the Heath Foundation, an independent charity working to improve healthcare quality in the UK, funded our project to help local ‘improvement groups’ learn how to bring about specifically agreed developments, while simultaneously observing how the improvements worked out. By formatively evaluating the processes involved, the intention...

Participatory approaches to evaluating integrated care: the vital role for client inclusion and participation

To the Editor

We read with interest Eyre and colleagues' publication ‘What can a participatory approach to evaluation contribute to the field of integrated care?’ published in BMJ Quality & Safety on 6 December 2016.1 We agree with many of the points they raised including the need to shift from proving efficacy to promoting real-world implementation of integrated care. In our research to develop a quality framework to drive improvements in integrated care implementation, we uncovered similar issues regarding the role of leadership and the microprocesses of collaboration between providers.2

However, while Eyre and colleagues correctly point out the value of participatory research approaches, coproduction of knowledge between researchers and those with a stake in the application of knowledge, and the centrality of person-centred care in integrated care, they do not identify the absence of service users in their own research as an important omission.


Authors' response: 'What can a participatory approach to evaluation contribute to the field of integrated care?

We would like to thank Dr Sunderji and colleagues for their letter in response to our publication ‘What can a participatory approach to evaluation contribute to the field of integrated care?’ published in BMJ Quality and Safety on 6 December 2016. Dr Sunderji and colleagues make an important challenge in their letter regarding the inclusion of service users in participatory research and evaluation. This is a challenge that we acknowledge and will make a brief response to here.

First, we wish to make it clear that we are in agreement that participatory research and evaluation should, wherever possible, be undertaken with full participation from all stakeholders including members of the public who use the service or services which form the object or objects of research or evaluation. In our own evaluation of the Waltham Forest and East London integrated care programme,1 2 we worked collaboratively...

Framework for direct observation of performance and safety in healthcare


Non-participant direct observation of healthcare processes offers a rich method for understanding safety and performance improvement. As a prospective method for error prediction and modelling, observation can capture a broad range of performance issues that can be related to higher aspects of the system.1–5 It can help identify underlying and recurrent problems6 that may be antecedents to more serious situations.7 It is also a way to understand the complexity of healthcare work that might otherwise be poorly understood or ignored,8 9 how workarounds influence work practices and safety,10 and is of fundamental importance to practitioners wishing to understand resilience in the face of conflicting workplace pressures.11 12 In some cases it will lead to the direct observation of near-misses or precursor events that...

Compassionate care: not easy, not free, not only nurses

Compassion has historically been defined as an underpinning principle of work conducted by health professionals, especially nurses.1 Numerous definitions of compassionate care exist, incorporating a range of elements. Most include a cognitive element: understanding what is important to the other by exploring their perspective; a volitional element: choosing to act to try and alleviate the other’s disquiet; an affective element: actively imagining what the other is going through; an altruistic element: reacting to the other’s needs selflessly; and a moral element: to not show compassion may compound any pain or distress already being experienced by the other.2 3 Appeals for more compassionate care have become common within international discourses, through initiatives such as Schwartz Rounds established in America, Hearts in Healthcare in New Zealand, and the Asia Pacific Healthcare Hub of Charter for Compassion. In the UK, a policy document called Compassion in...

Remediation and rehabilitation programmes for health professionals: challenges for the future

‘To improve is to change; to be perfect is to change often.’

—Winston Churchill

Health professions regulatory authorities are responsible for assessing the clinical performance of healthcare professionals.1 2 Some of them also have the responsibility for programming remediation interventions for health professionals with deficits in clinical performance.2 3 Available data on medical errors, malpractice claims, disciplinary actions and various other sources suggest that between 6% and 12% of physicians meet criteria for ‘dyscompetence’ in the USA.4 5 Elsewhere, the percentage varies according to the data sources.6 In Ontario, for instance, where the data come from randomly selected physicians, it is estimated that approximately 15% of family physicians and 3% of specialists have considerable deficiencies.4 7 8 Performance problems can have an impact on quality of care and...

Handoffs: whats good for residents is good for nurses...so whats next?

Communicating patient information at shift change is a time-honoured nursing tradition. Historically referred to as ‘giving report’, the methods and information shared during nursing handoffs varied widely in modality (eg, face to face or through audio recordings), location (eg, in the break room, unit work centre or bedside) and format (eg, notes, formatted document or electronic health record). Although the shift change handoff process has evolved to increasingly emphasise face-to-face exchange and required data elements, variability persists,1 and the shift transition remains a vulnerable time for patients.

Shift changes generally, and the nursing handoff specifically, create gaps in care where errors may occur. In this issue of BMJ Quality and Safety, Starmer and colleagues2 describe a framework, IPASS, to bridge this gap. IPASS stands for Illness severity; Patient summary, Action list; Situation awareness and contingency planning; and Synthesis by receiver. IPASS is a handoff improvement bundle that provides a standardised structure...

Compassionate care: constitution, culture or coping?

Alongside concern about avoidable mortality, one of the key findings of the public enquiry into failings at Mid Staffordshire NHS Foundation Trust,1 which ran Stafford Hospital in England, was the lack of compassion in care delivery. Sir Robert Francis, who led the enquiry, laid the blame for the compassion deficit at the door nursing and support staff. He recommended, among other things, that people should work as care assistants prior to nurse training and that values-based recruitment should be used to ensure that the ‘right’ people are recruited to be nurses. However, there has been little evidence to support these propositions. For example Snowden et al2 found that nursing students who had previous care jobs scored no higher for emotional intelligence than those without prior experience.

More recently opinion has shifted to the impact of compassionate leadership3 and compassionate environments on team behaviours....