Showing papers in "International Journal for Quality in Health Care in 2019"

The Danish unique personal identifier and the Danish Civil Registration System as a tool for research and quality improvement

Abstract: All countries want to improve the health of their populations and to improve the quality of care and patient safety. Consequently, there is an ongoing need to assess and document population health, the quality of care and patient safety using valid and reliable data. This requires the ability to monitor the same individuals over time as they receive prevention, diagnostics, treatments, care and rehabilitation and experience improvements or deteriorations in their health or healthcare. This is, however, a challenge for most healthcare systems. A prerequisite to such data is the unique personal identifier. This perspective on quality paper describes the experience with the unique personal identifier in Denmark, based on the Danish Civil Registration System (DCRS) as a tool for research in epidemiology, health services research, quality improvement and patient safety. DCRS has been celebrating its 50 years anniversary.

Validity of World Health Organisation prescribing indicators in Namibia's primary healthcare: findings and implications.

Abstract: Objective World Health Organization/International Network of Rational use of Drugs (WHO/INRUD) indicators are widely used to assess medicine use. However, there is limited evidence on their validity in Namibia's primary health care (PHC) to assess the quality of prescribing. Consequently, our aim was to address this. Design, setting, participants and interventions An analytical cross-sectional survey design was used to examine and validate WHO/INRUD indicators in out-patient units of two PHC facilities and one hospital in Namibia from 1 February 2015 to 31 July 2015. The validity of the indicators was determined using two-by-two tables against compliance to the Namibian standard treatment guidelines (NSTG). The receiver operator characteristics for the WHO/INRUD indicators were plotted to determine their accuracy as predictors of compliance to agreed standards. A multivariate logistic model was constructed to independently determine the prediction of each indicator. Main outcomes and results Out of 1243 prescriptions; compliance to NSTG prescribing in ambulatory care was sub-optimal (target was >80%). Three of the four WHO/INRUD indicators did not meet Namibian or WHO targets: antibiotic prescribing, average number of medicines per prescription and generic prescribing. The majority of the indicators had low sensitivity and/or specificity. All WHO/INRUD indicators had poor accuracy in predicting rational prescribing. The antibiotic prescribing indicator was the only covariate that was a significant independent risk factor for compliance to NSTGs. Conclusion WHO/INRUD indicators showed poor accuracy in assessing prescribing practices in ambulatory care in Namibia. There is need for appropriate models and/or criteria to optimize medicine use in ambulatory care in the future.

Life after sepsis: an international survey of survivors to understand the post-sepsis syndrome.

Abstract: OBJECTIVE In this study, we aim to describe the post-sepsis syndrome from the perspective of the sepsis survivors. DESIGN AND SETTING The study is a prospective, observational online international survey. PARTICIPANTS Sepsis survivors enrolled via social media from 13 September 2014 to 13 September 2016. INTERVENTIONS None. MAIN OUTCOME MEASURES Physiologic, physical and psychological function post-sepsis; and patient satisfaction with sepsis-centered care. RESULTS 1731 completed surveys from 41 countries were analyzed, with 79.9% female respondents, age 47.6 ± 14.4 years. The majority of respondents (47.8%) had sepsis within the last year. Survivors reported an increase in sensory, integumentary, digestive, breathing, chest pain, kidney and musculoskeletal problems after sepsis (all P-value <0.0001). Physical functions such as daily chores, running errands, spelling, reading and reduced libido posed increased difficulty (all P-value <0.0001). Within 7 days prior to completing the survey, the survivors reported varying degrees of anxiety, depression, fatigue and sleep disturbance. Sepsis survivors reported dissatisfaction with a number of hospital support services, with up to 29.3% of respondents stating no social services support was provided for their condition. CONCLUSIONS Sepsis survivors suffer from a myriad of physiologic, physical and psychological challenges. Survivors overall reveal dissatisfaction with sepsis-related care, suggesting areas for improvement both in-hospital and post-discharge.

Dimensions of service quality in healthcare: a systematic review of literature.

Abstract: Purpose Various dimensions of healthcare service quality were used and discussed in literature across the globe. This study presents an updated meaningful review of the extensive research that has been conducted on measuring dimensions of healthcare service quality. Data sources Systematic review method in current study is based on PRISMA guidelines. We searched for literature using databases such as Google, Google Scholar, PubMed and Social Science, Citation Index. Study selection In this study, we screened 1921 identified papers using search terms/phrases. Snowball strategies were adopted to extract published articles from January 1997 till December 2016. Data extraction Two-hundred and fourteen papers were identified as relevant for data extraction; completed by two researchers, double checked by the other two to develop agreement in discrepancies. In total, 74 studies fulfilled our pre-defined inclusion and exclusion criteria for data analysis. Data synthesis Service quality is mainly measured as technical and functional, incorporating many sub-dimensions. We synthesized the information about dimensions of healthcare service quality with reference to developed and developing countries. 'Tangibility' is found to be the most common contributing factor whereas 'SERVQUAL' as the most commonly used model to measure healthcare service quality. Conclusion There are core dimensions of healthcare service quality that are commonly found in all models used in current reviewed studies. We found a little difference in these core dimensions while focusing dimensions in both developed and developing countries, as mostly SERVQUAL is being used as the basic model to either generate a new one or to add further contextual dimensions. The current study ranked the contributing factors based on their frequency in literature. Based on these priorities, if factors are addressed irrespective of any context, may lead to contribute to improve healthcare quality and may provide an important information for evidence-informed decision-making.

Opportunities for intervention: stroke treatments, disability and mortality in urban Tanzania

Abstract: OBJECTIVE Given the high post-stroke mortality and disability and paucity of data on the quality of stroke care in Sub-Saharan Africa, we sought to characterize the implementation of stroke-focused treatments and 90-day outcomes of neuroimaging-confirmed stroke patients at the largest referral hospital in Tanzania DESIGN Prospective cohort study SETTING Muhimbili National Hospital (MNH) in Dar es Salaam, July 2016-March 2017 PARTICIPANTS Adults with new-onset stroke (<14 days), confirmed by head CT, admitted to MNH MAIN OUTCOMES MEASURES Modified Rankin scale (mRS) and vital status RESULTS Of 149 subjects (mean age 57; 48% female; median NIH stroke scale (NIHSS) 19; 46% ischemic stroke; 54% hemorrhagic), implementation of treatments included: dysphagia screening (80%), deep venous thrombosis prophylaxis (0%), aspirin (83%), antihypertensives (89%) and statins (95%) There was limited ability to detect atrial fibrillation and carotid artery disease and no acute thrombolysis or thrombectomy Of ischemic subjects, 19% died and 56% had severe disability (mRS 4-5) at discharge; 49% died by 90 days Of hemorrhagic subjects, 33% died and 49% had severe disability at discharge; 50% died by 90 days In a multivariable model, higher NIHSS score but not dysphagia, unconsciousness, or patient age was predictive of death by 90 days CONCLUSIONS The 90-day mortality of stroke presenting at MNH is 50%, much higher than in higher income settings Although severe stroke presentations are a major factor, efforts to improve the quality of care and prevent complications of stroke are urgently needed Acute stroke interventions with low number needed to treat represent challenging long-term goals

The Korean Triage and Acuity Scale: Associations with admission, disposition, mortality and length of stay in the emergency department

Abstract: OBJECTIVE The Korean Triage and Acuity Scale (KTAS) was implemented in our emergency department (ED) in May 2016 and is fully integrated into the electronic medical record (EMR) system. Our objective was to determine whether the KTAS is associated with changes in admissions to the hospital, admission disposition, inpatient mortality and length of stay (LOS). DESIGN Quasi-experimental, uncontrolled before-and-after study. SETTING The urban tertiary teaching hospital with 1100 beds and receives approximately annual 90 000 ED visits. PARTICIPANTS 122 370 patients who visited the ED during the before-and-the after period. INTERVENTIONS ED staff were educated on the KTAS for 1 month, after which the KTAS evaluation period began. Admission, disposition, mortality and LOS were compared between the 'before' period (1 June 2015 to 30 April 2016) and the 'after' period (1 June 2016 to 30 April 2017). MAIN OUTCOME MEASURES Admissions to the hospital, admission disposition, inpatient mortality and LOS. RESULTS A total of 59 220 and 63 150 patients were included in the before-and-after periods of KTAS implementation, respectively. The pattern of admission and disposition changed significantly after implementation of the KTAS. The mean LOS was 343 min (standard deviation [SD] = 432 min) during the before period, which significantly decreased to 289 min (SD = 333 min) after implementation (P < 0.001). The total mortality rate was significantly reduced after implementation of the KTAS (213 (0.36%) vs. 179 (0.28%), P = 0.020). CONCLUSION Implementation of the KTAS changed admission and disposition patterns and reduced the LOS and mortality in the ED.

Successful Healthcare Improvements From Translating Evidence in complex systems (SHIFT-Evidence): simple rules to guide practice and research.

Abstract: Background Evidence translation and improvement research indicate that healthcare contexts are complex systems, characterized by uncertainty and surprise, which often defy orchestrated intervention attempts. This article reflects on the implications of complexity on attempts to translate evidence, and on a newly published framework for Successful Healthcare Improvements From Translating Evidence in complex systems (SHIFT-Evidence). Discussion SHIFT-Evidence positions the challenge of evidence translation within the complex and evolving context of healthcare, and recognizes the wider issues practitioners routinely face. It is empirically grounded, and designed to be comprehensive, practically relevant and actionable. SHIFT-evidence is summarized by three principles designed to be intuitive and memorable: 'act scientifically and pragmatically'; 'embrace complexity'; and 'engage and empower'. Common challenges and strategies to overcome them are summarized in 12 'simple rules' that provide actionable guidance. Conclusion SHIFT-Evidence provides a practical tool to guide practice and research of evidence translation and improvement within complex dynamic healthcare settings. Implications are that improvement initiatives and research study designs need to take into account the unique initial conditions in each local setting; conduct needs to respond to unpredictable effects and address dependent problems; and evaluation needs to be sensitive to evolving priorities and the emergent range of activities required to achieve improvement.

Quality of essential surgical care in low- and middle-income countries: a systematic review of the literature.

Abstract: Purpose Quality of care is an emerging area of focus in the surgical disciplines. However, much of the emphasis on quality is limited to high-income countries. To address this gap, we conducted a systematic review of the literature on the quality of essential surgical care in low- and middle- income countries (LMIC). Data sources We searched PubMed, Cinahl, Embase and CAB Abstracts using three domains: quality of care, surgery and LMIC. Study selection We limited our review to studies of essential surgeries that pertained to all three search domains. Data extraction We extracted data on study characteristics, type of surgery and the way in which quality was studied. Results of data synthesis 354 studies were included. 281 (79.4%) were single-center studies and nearly half (n = 169, 46.9%) did not specify the level of facility. 207 studies reported on mortality (58.47%) and 325 reported on a morbidity (91.81%), most commonly surgical site infection (n = 190, 53.67%). Of the Institute of Medicine domains of quality, studies were most commonly of safety (n = 310, 87.57%) and effectiveness (n = 180, 50.85%) and least commonly of equity (n = 21, 5.93%). Conclusion We find that while there are numerous studies that report on some aspects of quality of care, much of the data is single center and observational. Additionally, there is variability on which outcomes are reported both within and across specialties. Finally, we find under-reporting of parameters of equity and timeliness, which may be critical areas for research moving forward.

The impact of work-related stress on medication errors in Eastern Region Saudi Arabia

Abstract: OBJECTIVE To examine the relationship between overall level and source-specific work-related stressors on medication errors rate. DESIGN A cross-sectional study examined the relationship between overall levels of stress, 25 source-specific work-related stressors and medication error rate based on documented incident reports in Saudi Arabia (SA) hospital, using secondary databases. SETTING King Abdulaziz Hospital in Al-Ahsa, Eastern Region, SA. PARTICIPANTS Two hundred and sixty-nine healthcare professionals (HCPs). MAIN OUTCOME MEASURES The odds ratio (OR) and corresponding 95% confidence interval (CI) for HCPs documented incident report medication errors and self-reported sources of Job Stress Survey. RESULTS Multiple logistic regression analysis identified source-specific work-related stress as significantly associated with HCPs who made at least one medication error per month (P < 0.05), including disruption to home life, pressure to meet deadlines, difficulties with colleagues, excessive workload, income over 10 000 riyals and compulsory night/weekend call duties either some or all of the time. Although not statistically significant, HCPs who reported overall stress were two times more likely to make at least one medication error per month than non-stressed HCPs (OR: 1.95, P = 0.081). CONCLUSION This is the first study to use documented incident reports for medication errors rather than self-report to evaluate the level of stress-related medication errors in SA HCPs. Job demands, such as social stressors (home life disruption, difficulties with colleagues), time pressures, structural determinants (compulsory night/weekend call duties) and higher income, were significantly associated with medication errors whereas overall stress revealed a 2-fold higher trend.

Translating evidence in complex systems: a comparative review of implementation and improvement frameworks.

Abstract: Purpose An increasing number of implementation and improvement frameworks seek to describe and explain how change is made in healthcare This paper aims to explore how existing frameworks conceptualize the influence of complexity in translating evidence into practice in healthcare Data sources A database was interrogated using a search strategy to identify publications that present frameworks and models for implementation and improvement Study selection Ten popular implementation and improvement frameworks were purposively selected Data extraction Comparative analysis was conducted using an analytical framework derived from SHIFT-Evidence, a framework that conceptualizes complexity in implementation and improvement initiatives Results Collectively the frameworks accounted for key concepts of translating evidence in complex systems: understanding the uniqueness of each setting; the interdependency of practices/processes and the need to respond to unpredictable events and emergent learning The analysis highlighted heterogeneity of the frameworks in their focus on different aspects of complexity Differences include the extent to which problems and solutions are investigated or assumed; whether endpoints are defined as the uptake of interventions or achievement of goals; and emphasis placed on fixed-term interventions versus continual improvement None of the individual frameworks reviewed incorporated all the implications of complexity, as described by SHIFT-Evidence Conclusion This research identifies the differences in how implementation and improvement frameworks consider complexity, suggesting that SHIFT-Evidence offers a more comprehensive overview compared with the other frameworks The similarity of concepts across the frameworks suggests growing consensus in the literature, with SHIFT-Evidence providing a conceptual bridge between the implementation and improvement fields

Using Lean Six Sigma to improve rates of day of surgery admission in a national thoracic surgery department.

Abstract: OBJECTIVE The aim of this study is to improve rates of day of surgery admission (DOSA) for all suitable elective thoracic surgery patients. DESIGN Lean Six Sigma (LSS) methods were used to enable improvements to both the operational process and the organizational working of the department over a period of 19 months. SETTING A national thoracic surgery department in a large teaching hospital in Ireland. PARTICIPANTS Thoracic surgery staff, patients and quality improvement staff at the hospital. INTERVENTION(S) LSS methods were employed to identify and remove the non-value-add in the patient's journey and achieve higher levels of DOSA. A pre-surgery checklist and Thoracic Planning Meeting were introduced to support a multidisciplinary approach to enhanced recovery after surgery (ERAS), reduce rework, improve list efficiency and optimize bed management. MAIN OUTCOME MEASURE(S) To achieve DOSA for all suitable elective thoracic surgery patients in line with the National Key Performance Indicator of 75%. A secondary outcome would be to further decrease overall length of stay by 1 day. RESULTS Over a 19 month period, DOSA has increased from 10 to 75%. Duplication of preoperative tests reduced from 83 to <2%. Staff and patient surveys show increased satisfaction and improved understanding of ERAS. CONCLUSIONS Using LSS methods to improve both operational process efficiency and organizational clinical processes led to the successful achievement of increasing rates of DOSA in line with national targets.

Effectiveness of adherence to recommended clinical examinations of diabetic patients in preventing diabetes-related hospitalizations.

Abstract: OBJECTIVE To validate a set of indicators for quality of diabetes care through their relationship with measurable clinical outcomes DESIGN A retrospective cohort study was carried out from 2010 to 2015 SETTING Population-based study Data were retrieved from healthcare utilization databases of three Italian regions (Lombardy, Emilia Romagna and Lazio) on the whole covering 20 million citizens PARTICIPANTS The 77 285 individuals who were newly taken in care for diabetes during 2010 entered into the cohort INTERVENTIONS Exposure to selected clinical recommendations (ie periodic controls for glycated hemoglobin, lipid profile, urine albumin excretion, serum creatinine and dilated eye exams) was recorded MAIN OUTCOMES MEASURES A composite outcome was employed taking into account hospitalizations for brief-term diabetes complications, uncontrolled diabetes, long-term vascular outcomes and no traumatic lower limb amputation A multivariable proportional hazards model was fitted to estimate hazard ratio, and 95% confidence intervals (CI), for the exposure-outcome association RESULTS Among the newly taken in care patients with diabetes, those who adhered to almost none (0 or 1), just some (2 or 3) or almost all (4 or 5) recommendations during the first year after diagnosis were 44%, 36% and 20%, respectively Compared patients who adhered to almost none recommendation, significant risk reductions of 16% (95% CI, 6-24%) and 20% (7-28%) were observed for those who adhered to just some and almost all recommendations, respectively CONCLUSIONS Tight control of patients with diabetes through regular clinical examinations must to be considered the cornerstone of national guidance, national audits and quality improvement incentives schemes

A centralized automated-dispensing system in a French teaching hospital: return on investment and quality improvement.

Abstract: OBJECTIVES To evaluate the return on investment (ROI) and quality improvement after implementation of a centralized automated-dispensing system after 8 years of use. DESIGN Prospective evaluation of ROI; before and after study to evaluate dispensing errors; user satisfaction questionnaire after 8 years of use. SETTING The study was conducted at a French teaching hospital in the pharmacy department, which is equipped with decentralized automated medication cabinets in the wards. PARTICIPANTS Pharmacy staff (technicians and residents). INTERVENTION(S) Implementation of a centralized automated-dispensing robot. MAIN OUTCOME MEASURE(S) The true ROI was prospectively and annually compared to estimated returns calculated after implementation and upgrade of the robot; dispensing errors determined by observation of global deliveries and the satisfaction of users based on a validated questionnaire were evaluated. RESULTS Following the upgrade, we found little difference for the ROI (+1.86%). The payback period increased by almost 3 years. There was a significant reduction of dispensing errors, from 2.9% to 1.7% (P < 0.001). User satisfaction of the robot by the pharmacy staff was reported (score of 5.52 ± 1.20 out of 7). CONCLUSIONS These systems are worthwhile investments and largely contribute to improving the quality and safety of the medication process.

Low effective coverage of family planning and antenatal care services in Ethiopia

Abstract: OBJECTIVE To assess the quality and effective coverage (EC) of family planning (FP) and antenatal care (ANC) services in Ethiopia. DESIGN Secondary analyses of the 2014 Ethiopia Service Provision Assessment Plus Survey and 2016 Ethiopia Demographic and Health Survey data. SETTING AND PARTICIPANTS Women using FP and ANC. MAIN OUTCOME MEASURES Quality indices are created as a proportion of recommended clinical actions done in observations of ANC and FP visits. We adjust the crude coverage of ANC and of FP by the quality to estimate EC for both services. RESULTS The crude coverage of FP was 61% and 62% for ANC in Ethiopia in 2016. On average, quality was 35.8% during FP visits and 86% of women received <50% of the recommended clinical actions. When adjusting the crude coverage to account for the quality of service, Ethiopia's FP services EC was 22%. On average, ANC quality was 34% and 81% received <50% of the recommended ANC clinical actions. When adjusting the crude coverage by the service quality, the mean EC of ANC services was 22% in Ethiopia. CONCLUSIONS The quality of both FP and ANC services is low in Ethiopia, with women obtaining only a fraction of the standard clinical actions during their visits. In addition, there is considerable variation in EC across Ethiopia's regions, with variation driven largely by variations in crude coverage. To improve EC, actions are needed to improve the quality of ANC and FP care.

Coping with more people with more illness. Part 1: the nature of the challenge and the implications for safety and quality.

Abstract: Health systems are under more pressure than ever before, and the challenges are multiplying and accelerating. Economic forces, new technology, genomics, AI in medicine, increasing demands for care-all are playing a part, or are predicted to increasingly do so. Above all, ageing populations in many parts of the world are exacerbating the disease burden on the system and intensifying the requirements to provide effective care equitably to citizens. In this first of two companion articles on behalf of the Innovation and Systems Change Working Group of the International Society for Quality in Health Care (ISQua), in consultation with representatives from over 40 countries, we assess this situation and discuss the implications for safety and quality. Health systems will need to run ahead of the coming changes and learn how to cope better with more people with more chronic and acute illnesses needing care. This will require collective ingenuity, and a deep desire to reconfigure healthcare and re-engineer services. Chief amongst the successful strategies, we argue, will be preventative approaches targeting both physical and psychological health, paying attention to the determinants of health, keeping people at home longer, experimenting with new governance and financial models, creating novel incentives, upskilling workforces to fit them for the future, redesigning care teams and transitioning from a system delivering episodic care to one that looks after people across the life cycle. There are opportunities for the international community to learn together to revitalise their health systems in a time of change and upheaval.

Anticoagulant medication errors in hospitals and primary care: a cross-sectional study

Abstract: bjective: To assess the proportion of all medication error reports in hospitals and primary care that involved an anticoagulant. Secondary objectives were the anticoagulant involved, phase of the medication process in which the error occurred, causes and consequences of 1000 anticoagulant medication errors. Additional secondary objectives were the total number of anticoagulant medication error reports per month, divided by the total number of medication error reports per month and the proportion of causes of 1000 anticoagulant medication errors (comparing the preand post-guideline phase). Design: A cross-sectional study. Setting: Medication errors reported to the Central Medication incidents Registration reporting system. Participants: Between December 2012 and May 2015, 42 962 medication errors were reported to the CMR. Intervention: N/A. Main outcome measure: Proportion of all medication error reports that involved an anticoagulant. Phase of the medication process in which the error occurred, causes and consequences of 1000 anticoagulant medication errors. The total number of anticoagulant medication error reports per month, divided by the total number of medication error reports per month (comparing the preand post-guideline phase) and the total number of causes of 1000 anticoagulant medication errors before and after introduction of the LSKA 2.0 guideline. Results: Anticoagulants were involved in 8.3% of the medication error reports. A random selection of 1000 anticoagulant medication error reports revealed that low-molecular weight heparins were most often involved in the error reports (56.2%). Most reports concerned the prescribing phase of the medication process (37.1%) and human factors were the leading cause of medication errors mentioned in the reports (53.4%). Publication of the national guideline on integrated antithrombotic care had no effect on the proportion of anticoagulant medication error reports. Human factors were the leading cause of medication errors before and after publication of the guideline. Conclusions: Anticoagulant medication errors occurred in 8.3% of all medication errors. Most error reports concerned the prescribing phase of the medication process. Leading cause was human factors. The publication of the guideline had no effect on the proportion of anticoagulant medication errors.

The Ethiopia healthcare quality initiative: design and initial lessons learned.

Abstract: Objective To describe the development, implementation and initial outcomes of a national quality improvement (QI) intervention in Ethiopia. Design Retrospective descriptive study of initial prototype phase implementation outcomes. Setting All public facilities in one selected prototype district in each of four agrarian regions. Participants Facility QI teams composed of managers, healthcare workers and health extension workers. Interventions The Ethiopian Federal Ministry of Health (FMoH) and the Institute for Healthcare Improvement co-designed a three-pronged approach to accelerate health system improvement nationally, which included developing a national healthcare quality strategy (NHQS); building QI capability at all health system levels and introducing scalable district MNH QI collaboratives across four regions, involving healthcare providers and managers. Outcome measures Implementation outcomes including fidelity, acceptability, adoption and program effectiveness. Results The NHQS was launched in 2016 and governance structures were established at the federal, regional and sub-regional levels to oversee implementation. A total of 212 federal, regional and woreda managers have been trained in context-specific QI methods, and a national FMoH-owned in-service curriculum has been developed. Four prototype improvement collaboratives have been completed with high fidelity and acceptability. About 102 MNH change ideas were tested and a change package was developed with 83 successfully tested ideas. Conclusion The initial successes observed are attributable to the FMoH's commitment in implementing the initiative, the active engagement of all stakeholders and the district-wide approach utilized. Challenges included weak data systems and security concerns. The second phase-in 26 district-level collaboratives-is now underway.

The nature of patient complaints: a resource for healthcare improvements.

Abstract: Objective The aim of this study was to explore the nature, potential usefulness and meaning of complaints lodged by patients and their relatives. Design A retrospective, descriptive design was used. Setting The study was based on a sample of formal patient complaints made through a patient complaint reporting system for publicly funded healthcare services in Sweden. Participants A systematic random sample of 170 patient complaints was yielded from a total of 5689 patient complaints made in a Swedish county in 2015. Main outcome measure Themes emerging from patient complaints analysed using a qualitative thematic method. Results The patient complaints reported patients' or their relatives' experiences of disadvantages and problems faced when seeking healthcare services. The meanings of the complaints reflected six themes regarding access to healthcare services, continuity and follow-up, incidents and patient harm, communication, attitudes and approaches, and healthcare options pursued against the patient's wishes. Conclusions The patient complaints analysed in this study clearly indicate a number of specific areas that commonly give rise to dissatisfaction; however, the key findings point to the significance of patients' exposure and vulnerability. The findings suggest that communication needs to be improved overall and that patient vulnerability could be successfully reduced with a strong interpersonal focus. Prerequisites for meeting patients' needs include accounting for patients' preferences and views both at the individual and organizational levels.

Coping with more people with more illness. Part 2: new generation of standards for enabling healthcare system transformation and sustainability

Abstract: In Part 2 of this two-part contribution made on behalf of the Innovation and Systems Change Working Group of the International Society for Quality in Health Care (ISQua), we continue the argument for refashioning health systems in response to ageing and other pressures. Massive ageing in many countries and accompanying technological, fiscal and systems changes are causing the tectonic plates of healthcare to shift in ways not yet fully appreciated. In response, while things remain uncertain, we nevertheless have to find ways to proceed. We propose a strategy for stakeholders to pursue, of key importance and relevance to the ISQua: to harness flexible standards and external assessment in support of needed change. Depending on how they are used, healthcare standards and accreditation can promote, or hinder, the changes needed to create better healthcare for all in the future. Standards should support people's care needs across the life cycle, including prevention and health promotion. New standards that emphasise better coordination of care, those that address the entire healthcare journey and standards that reflect and predict technological changes and support new models of care can play a part. To take advantage of these opportunities, governance bodies, external assessment agencies and other authorities will need to be less prescriptive and better at developing more flexible standards that apply to the entire health journey, incorporating new definitions of excellence and acceptability. The ISQua welcomes playing a leadership role.

A framework to support risk assessment in hospitals

Abstract: Quality problem or issue A number of challenges have been identified with current risk assessment practice in hospitals, including: a lack of consultation with a sufficiently wide group of stakeholders; a lack of consistency and transparency; and insufficient risk assessment guidance Consequently, risk assessment may not be fully effective as a means to ensure safety Initial assessment We used a V system developmental model, in conjunction with mixed methods, including interviews and document analysis to identify user needs and requirements Choice of solution One way to address current challenges is through providing good guidance on the fundamental aspects of risk assessment We designed a risk assessment framework, comprising: a risk assessment model that depicts the main risk assessment steps; risk assessment explanation cards that provide prompts to help apply each step; and a risk assessment form that helps to systematize the risk assessment and document the findings Implementation We conducted multiple group discussions to pilot the framework through the use of a representative scenario and used our findings for the user evaluation Evaluation User evaluation was conducted with 10 participants through interviews and showed promising results Lessons learned While the framework was recommended for use in practice, it was also proposed that it be adopted as a training tool With its use in risk assessment, we anticipate that risk assessments would lead to more effective decisions being made and more appropriate actions being taken to minimize risks Consequently, the quality and safety of care delivered could be improved

The role of organizational and professional cultures in medication safety: a scoping review of the literature.

Abstract: Purpose This scoping review explores what is known about the role of organizational and professional cultures in medication safety. The aim is to increase our understanding of 'cultures' within medication safety and provide an evidence base to shape governance arrangements. Data sources Databases searched are ASSIA, CINAHL, EMBASE, HMIC, IPA, MEDLINE, PsycINFO and SCOPUS. Study selection Inclusion criteria were original research and grey literature articles written in English and reporting the role of culture in medication safety on either organizational or professional levels, with a focus on nursing, medical and pharmacy professions. Articles were excluded if they did not conceptualize what was meant by 'culture' or its impact was not discussed. Data extraction Data were extracted for the following characteristics: author(s), title, location, methods, medication safety focus, professional group and role of culture in medication safety. Results of data synthesis A total of 1272 citations were reviewed, of which, 42 full-text articles were included in the synthesis. Four key themes were identified which influenced medication safety: professional identity, fear of litigation and punishment, hierarchy and pressure to conform to established culture. At times, the term 'culture' was used in a non-specific and arbitrary way, for example, as a metaphor for improving medication safety, but with little focus on what this meant in practice. Conclusions Organizational and professional cultures influence aspects of medication safety. Understanding the role these cultures play can help shape both local governance arrangements and the development of interventions which take into account the impact of these aspects of culture.

Quality assessment indicators in antenatal care worldwide: a systematic review.

Abstract: PURPOSE To describe indicators used for the assessment of antenatal care (ANC) quality worldwide under the World Health Organization (WHO) framework and based on a systematic review of the literature. DATA SOURCES Searches were performed in MEDLINE, SciELO, BIREME and Web of Science for eligible studies published between January 2002 and September 2016. STUDY SELECTION Original articles describing women who had received ANC, any ANC model and, any ANC quality indicators were included. DATA EXTRACTION Publication date, study design and ANC process indicators were extracted. RESULTS OF DATA SYNTHESIS Of the total studies included, 69 evaluated at least one type of ANC process indicator. According to WHO ANC guidelines, 8.7% of the articles reported healthy eating counseling and 52.2% iron and folic acid supplementation. The evaluation indicators on maternal and fetal interventions were: syphilis testing (55.1%), HIV testing (47.8%), gestational diabetes mellitus screening (40.6%) and ultrasound (27.5%). Essential ANC activities assessment ranged from 26.1% report of fetal heart sound, 50.7% of maternal weight and 63.8% of blood pressure. Regarding preventive measures recommended by WHO, tetanus vaccine was reported in 60.9% of the articles. Interventions performed by health services to improve use and quality of ANC care, promotion of maternal and fetal health, and the number of visits to the ANC were evaluated in 65.2% of the studies. CONCLUSION Numerous ANC content indicators are being used to assess ANC quality. However, there is a need to use standardized indicators across countries and efforts to improve quality evaluation.

Methods to measure quality of care and quality indicators through health facility surveys in low- and middle-income countries

Abstract: Objective Present methods to measure standardized, replicable and comparable metrics to measure quality of medical care in low- and middle-income countries. Design We constructed quality indicators for maternal, neonatal and child care. To minimize reviewer judgment, we transformed criteria from check-lists into data points and decisions into conditional algorithms. Distinct criteria were established for each facility level and type of care. Indicators were linked to discharge diagnoses. We designed electronic abstraction tools using computer-assisted personal interviewing software. Setting We present results for data collected in the poorest areas of Belize, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, Panama and the state of Chiapas in Mexico (January-October 2014). Results We collected data from 12 662 medical records. Indicators show variations of quality of care between and within countries. Routine interventions, such as quality antenatal care (ANC), immediate neonatal care and postpartum contraception, had low levels of compliance. Records that complied with quality ANC ranged from 68.8% [confidence interval (CI):64.5-72.9] in Costa Rica to 5.7% [CI:4.0-8.0] in Guatemala. Less than 25% of obstetric and neonatal complications were managed according to standards in all countries. Conclusions Our study underscores that, with adequate resources and technical expertise, collecting data for quality indicators at scale in low- and middle-income countries is possible. Our indicators offer a comparable, replicable and standardized framework to identify variations on quality of care. The indicators and methods described are highly transferable and could be used to measure quality of care in other countries.

Involving young people in health promotion, research and policy-making: practical recommendations.

Abstract: Youth is a dynamic and complex transition period in life where many factors jeopardise its present and future health. Youth involvement enables young people to influence processes and decisions that affect them, leading to changes in themselves and their environment (e.g. peers, services, communities and policies); this strategy could be applied to improve health and prevent diseases. Nonetheless, scientific evidence of involving youth in health-related programmes is scarce. The aim of this paper is to describe youth involvement as a health promotion strategy and to compile practical recommendations for health promoters, researchers and policy-makers interested in successful involvement of young people in health-related programmes. These suggestions aim to encourage a positive working synergy between adults and youth during the development, implementation and evaluation of policies, research and/or health promotion efforts that target adolescents.

Aggregate analysis of sentinel events as a strategic tool in safety management can contribute to the improvement of healthcare safety

Abstract: Objective To examine if clustering of root causes of sentinel events (SEs) can contribute to organisational improvement of healthcare and patient safety by providing insight into organisational risk factors, patterns and trends. Design Retrospective, cross-sectional review of SEs from a hospital database reported to the Board of directors in 2016. Setting A regional teaching hospital in the Netherlands. Intervention(s) Clustering of characteristics and variables of SEs to establish vulnerabilities and patterns of failure factors of the organisation. Main outcome measure(s) Characteristics and contributory causes of failure of SEs identified via root cause analysis (RCA). Outcomes reported using descriptive statistics. Results A total of 21 events were included involving 21 patients. Mean age was 56.7 years (SD 24.4), 71.4% were above 50 years of age. In 81.8%, the care was multi-disciplinary and in 76.2% the event resulted in permanent harm or injury. Of the 132 identified contributory root causes, most were related to human factors (53.8%) and organisational factors (40.2%). Technical and patient-related factors were identified in 3.0%. Organisational improvement strategies focused on the care of elderly patients, patients subjected to multi-disciplinary care and on improving knowledge, protocols and coordination of care. Conclusion Clustering variables of SEs and contributory factors of failure through RCA helps to delineate a hospital-specific profile by providing a detailed insight into risk factors, patterns and trends in an organisation and to determine the best strategies for improvement by drawing lessons across events.

Translating research on quality improvement in five European countries into a reflective guide for hospital leaders: the 'QUASER Hospital Guide'.

Abstract: Objective: The aim was to translate the findings of the QUASER study into a reflective, dialogic guide to help senior hospital leaders develop an organization wide QI strategy. Design: The QUASER study involved in depth ethnographic research into QI work and practices in two hospitals in each of five European countries. Three translational stakeholder workshops were held to review research findings and advise on the design of the Guide. An extended iterative process involving researchers from each participant country was then used to populate the Guide. Setting: The research was carried out in two hospitals in each of five European countries. Participants: In total, 389 interviews with healthcare practitioners and 803 hours of observations. Intervention: None. Main outcome measure: None. Results: The QUASER Hospital Guide was designed for leadership teams to diagnose their organization’s strengths and weaknesses in the eight QI challenges. The Guide supports organizational dialogue about QI challenges, enables leaders to share perspectives, and helps teams to develop solutions to their situated problems. The Guide includes extensive examples of QI strategies drawn from the data and is published online and on paper. Conclusions: The QUASER Hospital Guide is empirically based, draws on a dialogical approach to Organizational Development and complexity science and can facilitate hospital leadership teams to identify the best solutions for their organization.

Clustered domestic model of residential care is associated with better consumer rated quality of care.

Abstract: © The Author(s) 2018. Published by Oxford University Press in association with the International Society for Quality in Health Care. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

Validation of the person-centred coordinated care experience questionnaire (P3CEQ)

Abstract: Background Measuring patient experiences of healthcare is increasingly emphasized as a mechanism to measure, benchmark and drive quality improvement, clinical effectiveness and patient safety at both national and local NHS level. Person-centred coordinated care (P3C) is the conjunction of two constructs; person-centred care and care coordination. It is a complex intervention requiring support for changes to organizational structure and the behaviour of professionals and patients. P3C can be defined as: ‘care and support that is guided by and organized effectively around the needs and preferences of individuals’. Despite the vast array of PRMS available, remarkably few tools have been designed that efficiently probe the core domains of P3C. This paper presents the psychometric properties of a newly developed PREM to evaluate P3C from a patient perspective. Methods A customized EMIS search was conducted at 72 GP practices across the South West (Somerset, Devon and Cornwall) to identify 100 patients with 1 or more LTCs, and are frequent users of primary healthcare services. Partial Credit Rasch Modelling was conducted to identify dimensionality and internal consistency. Ecological validity and sensitivity to change were assessed as part of intervention designed to improve P3C in adults with multiple long-term conditions; comparisons were drawn between the P3CEQ and qualitative data. Results Response rate for the P3CEQ was 32.82%. A two-factor model was identified. Rasch analysis confirmed unidimensionality of each factor (using infit MSQ values between 0.5 and 1.5). High internal consistency was established for both factors; For the Person-centred scale Cronbach’s Alpha = 0.829, Person separation = 0.756 and for the coordination scale Cronbach’s alpha = 0.783, person separation = 0.672. Conclusions The P3CEQ is a valid and reliable measure of P3C. The P3C is considered to have strong face, construct and ecological validity, with demonstrable sensitivity to change in a primary healthcare intervention.

Pediatric clinician perspectives on communicating diagnostic uncertainty.

Abstract: Objective Diagnosis often evolves over time, involves uncertainty, and is vulnerable to errors. We examined pediatric clinicians' perspectives on communicating diagnostic uncertainty to patients' parents and how this occurs. Design We conducted semi-structured interviews, which were audiotaped, transcribed, and analyzed using content analysis. Two researchers independently coded transcripts and then discussed discrepancies to reach consensus. Setting A purposive sample of pediatric clinicians at two large academic medical institutions in Texas. Participants Twenty pediatric clinicians participated: 18 physicians, 2 nurse practitioners; 7 males, 13 females; 7 inpatient, 11 outpatient, and 2 practicing in mixed settings; with 0-16 years' experience post-residency. Intervention(s) None. Main outcome measure(s) Pediatric clinician perspectives on communication of diagnostic uncertainty. Results Pediatric clinicians commonly experienced diagnostic uncertainty and most were comfortable seeking help and discussing with colleagues. However, when communicating uncertainty to parents, clinicians used multiple considerations to adjust the degree to which they communicated. Considerations included parent characteristics (education, socioeconomic status, emotional response, and culture) and strength of parent-clinician relationships. Communication content included setting expectations, explaining the diagnostic process, discussing most relevant differentials, and providing reassurance. Responses to certain parent characteristics, however, were variable. For example, some clinicians were more open to discussing diagnostic uncertainty with more educated parents- others were less. Conclusions While pediatric clinicians are comfortable discussing diagnostic uncertainty with colleagues, how they communicate uncertainty to parents appears variable. Parent characteristics and parent-clinician relationships affect extent of communication and content discussed. Development and implementation of optimal strategies for managing and communicating diagnostic uncertainty can improve the diagnostic process.

An exploration of factors influencing inpatient nurses' care behaviour in an acute hospital setting.

Abstract: OBJECTIVE To examine factors influencing caring behaviour of nurses in Singapore. DESIGN Descriptive correlational study using Care Behaviour Inventory (CBI-24) questionnaire to assess nurses' perceptions of their caring behaviours. SETTING Acute tertiary hospital in Singapore. PARTICIPANTS A convenience sample of 167 full time registered nurses working in subsidized wards, with more than 1 year of experience in current practising ward were recruited. MAIN OUTCOME MEASURE(S) Nurses' perception of their caring behaviours. RESULTS Data analysis yielded a mean CBI score of 123.11 out of 144, indicating that nurses had a positive perception of their caring behaviours. Among the 4 CBI subscales, Respectfulness and Connectedness components of CBI were ranked the lowest with a mean score of 4.2 and 4.9, respectively. This indicated that although nurses generally performed adequate caring during patient care, they appeared to be lacking in the expressive aspect of caring. Significant differences (P < 0.05) were found among subgroups of nationality, ethnicity, religion and education level. Nurses' perception of their caring behaviours was positively correlated to their age and total working experience. Linear regression showed that age, religion, education level positively influenced nurses' perception of their caring behaviours. CONCLUSION Findings from this study raise awareness to the caring behaviours that nurses were lacking in and also offer valuable insights to the potential factors influencing nurses' caring behaviours. This information serves as a foundational knowledge to guide the development of interventions aimed to promote patient-centred care and improve quality of future nursing care.