People with an intellectual disability form a sizeable minority group. Estimates of prevalence vary, depending on criteria used, but it is thought that intellectual disability affects around 1%–2% of the world population.1 2 Intellectual disability is present when the following three criteria are met: a significantly reduced ability to understand new or complex information, or to learn and apply new skills (impaired intelligence); a reduced ability to cope independently (impaired social functioning); and beginning before adulthood, with a lasting effect on development.3 4

Health inequities

People with an intellectual disability experience stark health inequities. Understanding the causes of these inequities is important in making steps towards addressing them. The ‘Learning from Lives and Deaths’ (LeDeR) programme, which has investigated deaths of people with an intellectual disability and autistic people in England since 2016,5 contributes towards achieving such understanding....

The great art of learning is to understand but little at a time. —John Locke

Clinical debriefing (CD) is rapidly gaining traction as a valuable activity. CD is usually conducted as a guided exploration and reflection of clinical events in an attempt to bridge the gap between experience and understanding, with the ultimate aim of influencing future practice.1 CD has the potential to improve outcomes for staff, teams, patients and systems.2 3 The evidence for CD exists and continues to grow; benefits range from changes in staff attitudes4 to favourable outcomes following cardiac arrest.5 Despite this, some clinicians have been sceptical about the impact of CD, and there are various barriers which may limit implementation. These include lack of clear purpose, actual or perceived lack of time, lack of experienced debriefers and cultural resistance to change.6 Our...

Importance

Surgical complications represent a considerable proportion of hospital expenses. Therefore, interventions that improve surgical outcomes could reduce healthcare costs.

Objective

Evaluate the effects of implementing surgical outcome monitoring using control charts to reduce hospital bed-days within 30 days following surgery, and hospital costs reimbursed for this care by the insurer.

Design

National, parallel, cluster-randomised SHEWHART trial using a difference-in-difference approach.

Setting

40 surgical departments from distinct hospitals across France.

Participants

155 362 patients over the age of 18 years, who underwent hernia repair, cholecystectomy, appendectomy, bariatric, colorectal, hepatopancreatic or oesophageal and gastric surgery were included in analyses.

Intervention

After the baseline assessment period (2014–2015), hospitals were randomly allocated to the intervention or control groups. In 2017–2018, the 20 hospitals assigned to the intervention were provided quarterly with control charts for monitoring their surgical outcomes (inpatient death, intensive care stay, reoperation and severe complications). At each site, pairs, consisting of one surgeon and a collaborator (surgeon, anaesthesiologist or nurse), were trained to conduct control chart team meetings, display posters in operating rooms, maintain logbooks and design improvement plans.

Main outcomes

Number of hospital bed-days per patient within 30 days following surgery, including the index stay and any acute care readmissions related to the occurrence of major adverse events, and hospital costs reimbursed for this care per patient by the insurer.

Results

Postintervention, hospital bed-days per patient within 30 days following surgery decreased at an adjusted ratio of rate ratio (RRR) of 0.97 (95% CI 0.95 to 0.98; p<0.001), corresponding to a 3.3% reduction (95% CI 2.1% to 4.6%) for intervention hospitals versus control hospitals. Hospital costs reimbursed for this care per patient by the insurer significantly decreased at an adjusted ratio of cost ratio (RCR) of 0.99 (95% CI 0.98 to 1.00; p=0.01), corresponding to a 1.3% decrease (95% CI 0.0% to 2.6%). The consumption of a total of 8910 hospital bed-days (95% CI 5611 to 12 634 bed-days) and 2 615 524 (95% CI 32 366 to 5 405 528) was avoided in the intervention hospitals postintervention.

Conclusions

Using control charts paired with indicator feedback to surgical teams was associated with significant reductions in hospital bed-days within 30 days following surgery, and hospital costs reimbursed for this care by the insurer.

Trial registration number

NCT02569450.

Objective

To evaluate rates, risk factors and outcomes of delayed diagnosis of seven serious paediatric conditions.

Methods

This was a retrospective, cross-sectional study of children under 21 years old visiting 13 community and tertiary emergency departments (EDs) with appendicitis, bacterial meningitis, intussusception, mastoiditis, ovarian torsion, sepsis or testicular torsion. Delayed diagnosis was defined as having a previous ED encounter within 1 week in which the condition was present per case review. Patients with delayed diagnosis were each matched to four control patients without delay by condition, facility and age. Conditional logistic regression models evaluated risk factors of delay. Complications were compared between by delayed diagnosis status.

Results

Among 14 972 children, delayed diagnosis occurred in 1.1% (range 0.3% for sepsis to 2.6% for ovarian torsion). Hispanic (matched OR 2.71, 95% CI 1.69 to 4.35) and non-Hispanic black (OR 2.40, 95% CI 1.21 to 4.79) race/ethnicity were associated with delayed diagnosis, whereas Asian and other race/ethnicity were not. Public (OR 2.21, 95% CI 1.42 to 3.44) and other (OR 2.43, 95% CI 1.50 to 3.93) insurance were also associated with delay. Non-English language was associated with delay (OR 1.65, 95% CI 1.02 to 2.69). Abnormal vital signs were associated with a lower likelihood of delay (OR 0.15, 95% CI 0.09 to 0.25). In an adjusted model, Hispanic race/ethnicity, other insurance, abnormal vital signs and complex chronic conditions (CCCs) were associated with delay. The odds of a complication were 2.5-fold (95% CI 1.6 to 3.8) higher among patients with a delay.

Conclusion

Delayed diagnosis was uncommon across 13 regional EDs but was more likely among children with Hispanic ethnicity, CCCs or normal vital signs. Delays were associated with a higher risk of complications.

Background

High-quality antenatal care is important for ensuring optimal birth outcomes and reducing risks of maternal and fetal mortality and morbidity. The COVID-19 pandemic disrupted the usual provision of antenatal care, with much care shifting to remote forms of provision. We aimed to characterise what quality would look like for remote antenatal care from the perspectives of those who use, provide and organise it.

Methods

This UK-wide study involved interviews and an online survey inviting free-text responses with: those who were or had been pregnant since March 2020; maternity professionals and managers of maternity services and system-level stakeholders. Recruitment used network-based approaches, professional and community networks and purposively selected hospitals. Analysis of interview transcripts was based on the constant comparative method. Free-text survey responses were analysed using a coding framework developed by researchers.

Findings

Participants included 106 pregnant women and 105 healthcare professionals and managers/stakeholders. Analysis enabled generation of a framework of the domains of quality that appear to be most relevant to stakeholders in remote antenatal care: efficiency and timeliness; effectiveness; safety; accessibility; equity and inclusion; person-centredness and choice and continuity. Participants reported that remote care was not straightforwardly positive or negative across these domains. Care that was more transactional in nature was identified as more suitable for remote modalities, but remote care was also seen as having potential to undermine important aspects of trusting relationships and continuity, to amplify or create new forms of structural inequality and to create possible risks to safety.

Conclusions

This study offers a provisional framework that can help in structuring thinking, policy and practice. By outlining the range of domains relevant to remote antenatal care, this framework is likely to be of value in guiding policy, practice and research.

Introduction

Clinical debriefing (CD) improves teamwork and patient care. It is implemented across a range of clinical contexts, but delivery and structure are variable. Furthermore, terminology to describe CD is also inconsistent and often ambiguous. This variability and the lack of clear terminology obstructs understanding and normalisation in practice. This review seeks to examine the contextual factors relating to different CD approaches with the aim to differentiate them to align with the needs of different clinical contexts.

Methods

Articles describing CD were extracted from Medline, CINAHL, ERIC, PubMed, PsychINFO and Academic Search Complete. Empirical studies describing CD that involved two or more professions were eligible for inclusion. Included papers were charted and analysed using the Who-What-When-Where-Why-How model to examine contextual factors which were then used to develop categories of CD. Factors relating to what prompted debriefing and when debriefing occurred were used to differentiate CD approaches.

Results

Forty-six papers were identified. CD was identified as either prompted or routine, and within these overarching categories debriefing was further differentiated by the timing of the debrief. Prompted CD was either immediate or delayed and routine CD was postoperative or end of shift. Some contextual factors were unique to each category while others were relatively heterogeneous. These categories help clarify the alignment between the context and the intention of CD.

Conclusions

The proposed categories offer a practical way to examine and discuss CD which may inform decisions about implementation. By differentiating CD according to relevant contextual factors, these categories may reduce confusion which currently hinders discourse and implementation. The findings from this review promote context-specific language and a shift away from conceptions of CD that embody a one-size-fits-all approach.

Objective

To identify factors acting as barriers or enablers to the process of healthcare consent for people with intellectual disability and to understand how to make this process equitable and accessible.

Data sources

Databases: Embase, MEDLINE, PsychINFO, PubMed, SCOPUS, Web of Science and CINAHL. Additional articles were obtained from an ancestral search and hand-searching three journals.

Eligibility criteria

Peer-reviewed original research about the consent process for healthcare interventions, published after 1990, involving adult participants with intellectual disability.

Synthesis of results

Inductive thematic analysis was used to identify factors affecting informed consent. The findings were reviewed by co-researchers with intellectual disability to ensure they reflected lived experiences, and an easy read summary was created.

Results

Twenty-three studies were included (1999 to 2020), with a mix of qualitative (n=14), quantitative (n=6) and mixed-methods (n=3) studies. Participant numbers ranged from 9 to 604 people (median 21) and included people with intellectual disability, health professionals, carers and support people, and others working with people with intellectual disability. Six themes were identified: (1) health professionals’ attitudes and lack of education, (2) inadequate accessible health information, (3) involvement of support people, (4) systemic constraints, (5) person-centred informed consent and (6) effective communication between health professionals and patients. Themes were barriers (themes 1, 2 and 4), enablers (themes 5 and 6) or both (theme 3).

Conclusions

Multiple reasons contribute to poor consent practices for people with intellectual disability in current health systems. Recommendations include addressing health professionals’ attitudes and lack of education in informed consent with clinician training, the co-production of accessible information resources and further inclusive research into informed consent for people with intellectual disability.

PROSPERO registration

CRD42021290548.

Introduction

Across the globe, awareness of racial and ethnic health inequities and the need for healthcare systems to address them are growing.1 In many countries, teams working in healthcare institutions are encouraged to stratify quality metrics by race and ethnicity as part of the movement to identify and disrupt health inequities.2 The lack of standard definitions for race and ethnicity and restrictions on how and where these data can be collected make collecting high-quality data challenging. Stratifying quality metrics by race and ethnicity is further challenged by the risk of undermining the core goal of disrupting inequities.1 Although presenting patient data stratified by race and ethnicity helps identify health inequities, such data can also reinforce the belief that differences in health outcomes are caused by biological instead of social and structural factors. The myth that race is a biological construct is dangerous...

The use of checklists in surgery is a best practice.1 There is a plethora of evidence that suggests using the WHO Surgical Safety Checklist (SSC) reduces complications such as pneumonia,2 intraoperative blood loss,2 3 sepsis,2 unplanned intubation,2 urinary tract infections,2 wound infections,2–4 30-day readmissions and 30-day mortality.2–4 The SSC has three components, which need to be carried out for each phase of a surgical procedure, including sign-in, timeout and sign-out.5 The SSC serves as an aide memoir that includes vital information to prompt team discussions and actions that may otherwise be overlooked or forgotten, thereby promoting clear, consistent and timely communications among team members that prevents errors and enhances patient safety.6 Importantly, the SSC is more than merely a...

Depending on your perspective, a unicorn could be either a magical horned creature or a billion-dollar start-up. Alternatively, it could represent coordinated care for patients with heart failure with preserved ejection fraction (HFpEF), as it does for Brooman-White et al.1 In their accompanying paper on coordination of care for patients with HFpEF, which included an analysis of 12 clinical guidelines and secondary analysis of qualitative interviews with patients and healthcare professionals in the UK’s National Health Service, the authors describe the apparent illusiveness of securing coordinated specialist and generalist care for this complex patient group. However, by explicating when and why problems arise, Brooman-White et al offer hope that the pursuit of coordinated care is not really as illusive as the unicorn they describe it as, but rather an elusive challenge which requires renewed focus and strategies designed around the needs of patients who use these services....

Thinkers from the broad field of quality management, such as Edwards Deming, have influenced the more focused field of healthcare quality including international organisations such as the Institute for Healthcare Improvement and The Health Foundation. Quality management was initially established for industrial settings but has since been applied in many other sectors such as education, travel and, in this context, healthcare. Quality management encompasses quality assurance, control and improvement. Healthcare practitioners and researchers have applied aspects of these in examples such Benneyan et al1 who in their much-cited text apply statistical process control in healthcare quality improvement using standard techniques developed in quality management. Other industrial research fields such as change management and organisational culture have also been adopted by the healthcare quality field. The value of learning from these fields was summarised by Davies et al2 who noted that ‘there is a rich literature...

For many women, fetal well-being in labour is assessed using continuous electronic fetal monitoring with cardiotocography (CTG), a technique used to monitor the fetal heartbeat and uterine contractions during pregnancy and labour.1 However, problems in the assessment of fetal well-being in labour and delays in escalation and response have been consistently highlighted in maternity care safety inquiries, both in the UK and internationally, causing untold distress to parents and families.2–6

Taking an interdisciplinary perspective, drawing on both human factors/ergonomics and social science, the study from Lamé and colleagues,7 published in this issue of BMJ Quality and Safety, aims to understand the everyday practice of electronic fetal monitoring with CTG and the organisational and work context within which this takes place. Findings are based on ethnographic observations and interviews with midwives and doctors at different levels...

Introduction

The WHO Surgical Safety Checklist (SSC) is a communication tool that improves teamwork and patient outcomes. SSC effectiveness is dependent on implementation fidelity. Administrative audits fail to capture most aspects of SSC implementation fidelity (ie, team communication and engagement). Existing research tools assess behaviours during checklist performance, but were not designed for routine quality assurance and improvement. We aimed to create a simple tool to assess SSC implementation fidelity, and to test its reliability using video simulations, and usability in clinical practice.

Methods

The Checklist Performance Observation for Improvement (CheckPOINT) tool underwent two rounds of face validity testing with surgical safety experts, clinicians and quality improvement specialists. Four categories were developed: checklist adherence, communication effectiveness, attitude and engagement. We created a 90 min training programme, and four trained raters independently scored 37 video simulations using the tool. We calculated intraclass correlation coefficients (ICC) to assess inter-rater reliability (ICC>0.75 indicating excellent reliability). We then trained two observers, who tested the tool in the operating room. We interviewed the observers to determine tool usability.

Results

The CheckPOINT tool had excellent inter-rater reliability across SSC phases. The ICC was 0.83 (95% CI 0.67 to 0.98) for the sign-in, 0.77 (95% CI 0.63 to 0.92) for the time-out and 0.79 (95% CI 0.59 to 0.99) for the sign-out. During field testing, observers reported CheckPOINT was easy to use. In 98 operating room observations, the total median (IQR) score was 25 (23–28), checklist adherence was 7 (6–7), communication effectiveness was 6 (6–7), attitude was 6 (6–7) and engagement was 6 (5–7).

Conclusions

CheckPOINT is a simple and reliable tool to assess SSC implementation fidelity and identify areas of focus for improvement efforts. Although CheckPOINT would benefit from further testing, it offers a low-resource alternative to existing research tools and captures elements of adherence and team behaviours.

Background

Patients with heart failure with preserved ejection fraction (HFpEF) are a complex and underserved group. They are commonly older patients with multiple comorbidities, who rely on multiple healthcare services. Regional variation in services and resourcing has been highlighted as a problem in heart failure care, with few teams bridging the interface between the community and secondary care. These reports conflict with policy goals to improve coordination of care and dissolve boundaries between specialist services and the community.

Aim

To explore how care is coordinated for patients with HFpEF, with a focus on the interface between primary care and specialist services in England.

Methods

We applied systems thinking methodology to examine the relationship between work-as-imagined and work-as-done for coordination of care for patients with HFpEF. We analysed clinical guidelines in conjunction with a secondary applied thematic analysis of semistructured interviews with healthcare professionals caring for patients with HFpEF including general practitioners, specialist nurses and cardiologists and patients with HFpEF themselves (n=41). Systems Thinking for Everyday Work principles provided a sensitising theoretical framework to facilitate a deeper understanding of how these data illustrate a complex health system and where opportunities for improvement interventions may lie.

Results

Three themes (working with complexity, information transfer and working relationships) were identified to explain variability between work-as-imagined and work-as-done. Participants raised educational needs, challenging work conditions, issues with information transfer systems and organisational structures poorly aligned with patient needs.

Conclusions

There are multiple challenges that affect coordination of care for patients with HFpEF. Findings from this study illuminate the complexity in coordination of care practices and have implications for future interventional work.

Background

Problems in intrapartum electronic fetal monitoring with cardiotocography (CTG) remain a major area of preventable harm. Poor understanding of the range of influences on safety may have hindered improvement. Taking an interdisciplinary perspective, we sought to characterise the everyday practice of CTG monitoring and the work systems within which it takes place, with the goal of identifying potential sources of risk.

Methods

Human factors/ergonomics (HF/E) experts and social scientists conducted 325 hours of observations and 23 interviews in three maternity units in the UK, focusing on how CTG tasks were undertaken, the influences on this work and the cultural and organisational features of work settings. HF/E analysis was based on the Systems Engineering Initiative for Patient Safety 2.0 model. Social science analysis was based on the constant comparative method.

Results

CTG monitoring can be understood as a complex sociotechnical activity, with tasks, people, tools and technology, and organisational and external factors all combining to affect safety. Fetal heart rate patterns need to be recorded and interpreted correctly. Systems are also required for seeking the opinions of others, determining whether the situation warrants concern, escalating concerns and mobilising response. These processes may be inadequately designed or function suboptimally, and may be further complicated by staffing issues, equipment and ergonomics issues, and competing and frequently changing clinical guidelines. Practice may also be affected by variable standards and workflows, variations in clinical competence, teamwork and situation awareness, and the ability to communicate concerns freely.

Conclusions

CTG monitoring is an inherently collective and sociotechnical practice. Improving it will require accounting for complex system interdependencies, rather than focusing solely on discrete factors such as individual technical proficiency in interpreting traces.

Clinical tools for use in practice—such as medicine reconciliation charts, diagnosis support tools and track-and-trigger charts—are endemic in healthcare, but relatively little attention is given to how to optimise their design. User-centred design approaches and co-design principles offer potential for improving usability and acceptability of clinical tools, but limited practical guidance is currently available. We propose a framework (FRamework for co-dESign of Clinical practice tOols or ‘FRESCO’) offering practical guidance based on user-centred methods and co-design principles, organised in five steps: (1) establish a multidisciplinary advisory group; (2) develop initial drafts of the prototype; (3) conduct think-aloud usability evaluations; (4) test in clinical simulations; (5) generate a final prototype informed by workshops. We applied the framework in a case study to support co-design of a prototype track-and-trigger chart for detecting and responding to possible fetal deterioration during labour. This started with establishing an advisory group of 22 members with varied expertise. Two initial draft prototypes were developed—one based on a version produced by national bodies, and the other with similar content but designed using human factors principles. Think-aloud usability evaluations of these prototypes were conducted with 15 professionals, and the findings used to inform co-design of an improved draft prototype. This was tested with 52 maternity professionals from five maternity units through clinical simulations. Analysis of these simulations and six workshops were used to co-design the final prototype to the point of readiness for large-scale testing. By codifying existing methods and principles into a single framework, FRESCO supported mobilisation of the expertise and ingenuity of diverse stakeholders to co-design a prototype track-and-trigger chart in an area of pressing service need. Subject to further evaluation, the framework has potential for application beyond the area of clinical practice in which it was applied.

Introduction

Perfection in this science, or rather art [i.e. medicine] takes longer to be mastered than human life [affords]—Maimonides, philosopher and physician, Middle Ages.1

A veritable quality improvement (QI) industry has emerged that centres around initiatives to improve patient outcomes or health system performance. These initiatives often target high-risk and high-cost disease states,2 with common foci of reducing waste,3 ‘hot-spotting’4 and readmissions.5 While these initiatives can help improve health system performance across the Quintuple Aim,6 they often fall short of achieving sustained improvements in outcomes at scale due to short attention spans, limited resources and shifting priorities or incentives.7–9 Furthermore, improvement initiatives can have unintended negative consequences that increase staff burnout and inadvertently exacerbate health human resource challenges,10 highlighting a need to clarify what we are trying...

The challenge

Despite progress in many areas, the world continues to face significant and growing challenges to the delivery of high-quality healthcare. Consistently high levels of avoidable harm are reported internationally.1 Inequities in quality persist and solutions are in short supply.2 Implementing initiatives to increase the uptake of effective care and de-implement ineffective technologies has also proven difficult.3 4 Patient-centred care is on the ‘to do’ list for healthcare systems but in too many instances it is deprioritised by decisions that seem arbitrary and not connected to any clear ethical framework.5 Delayed care is another widespread problem and we have long known that crude top-down solutions such as targets are unlikely to work.6

These challenges are formidable and exist against a backdrop of demographic pressures, staffing crises and financial constraints. In the context of these challenges,...

Safety cases in industry

In the UK and several other countries, including Norway, Australia and New Zealand, operators of safety-critical systems, such as nuclear power plants, public transportation systems and defence equipment, must develop a safety case to demonstrate that their systems are acceptably safe to operate.1 In these countries, the development, review and maintenance of safety cases are regulatory requirements. In the UK, this regulatory practice extends as of October 2023 to high-rise residential buildings following the Grenfell Tower fire in 2017, during which 72 people died.

So, why are these countries promoting the safety case approach across their safety-critical industries? The most tangible reason is the shift from a prescriptive regulatory regime towards a goal-based approach.2 In this approach, regulators establish overall safety goals, offering developers and system operators flexibility to determine the most suitable methods for ensuring compliance. A safety argument...

It is widely known—among healthcare professionals as well as patient safety researchers—that transfers of care are a high-risk area in relation to patient safety.1 And even more importantly, the experience of patients and their families suggests likewise. For example, in a research priority setting exercise focusing on safe care for adults with complex health needs, 6 of the top 10 priorities related to transfers of care, either within or between organisations.2 While care transitions affect all elements of a person’s care, medication safety is a particular cause for concern, with a Cochrane review finding that 56% of patients are at risk of having at least one medication discrepancy as part of standard care.3 Accepted wisdom among many people working in the quality and safety field is that measurement is essential both to understand the risks and to target and evaluate interventions to address...