Quality Improvement News

January 14, 2016 | A few years ago, IHI and others began suggesting to providers that instead of routinely asking patients “What’s the matter with you?” they should begin asking “What matters to you?”

Don Berwick, president emeritus and senior fellow at the Institute for Healthcare Improvement, and the former head of CMS, advocates for a single-payer system and for bringing "pride and joy" to the workplace among physicians, nurses, administrators, and executives who are all involved in doing the work of caring.

In this article, Institute for Healthcare Improvement VP Andrea Kabcenell discusses how IHI realized sepsis' significant toll on patients, and over the past several years has taken on reducing mortality from the infection.

This article highlights North Shore-LIJ and other hospitals' adoption of IHI's methodology to address sepsis and support process re-engineering.

Art and science have their meeting point in method.

—Earl Edward George Bulwer-Lytton, Caxtoniana (1875), 303

The handoff or handover of patient care is not just a simple act of communication. It is a complex exchange of patient information that increases the likelihood of safe and effective care. We know that these transfers of care are a vulnerable link in patient care that is associated with preventable adverse events. It is especially concerning that effective handoff communication is not regularly or systematically taught to health professionals.

It is the interaction between the ‘sender’ and the ‘receiver’ that matters. Accurate transmission from the sender is not sufficient and without questions may result in a handoff ‘telegram’.1 The solution to the telegram problem lies partly with the sender and the information they transmit and with the receiver and their ability to ask the right questions—the handoff conversation,...

Introduction

Improving patient safety during handovers has become a public health priority.1 Over the past decade, a number of best practices have emerged, which, taken together, represent the first generation of handover interventions. Largely adapted from industries (such as aviation and railroad) in which transition errors have high consequences,2 these first-generation best practices aim to reduce information loss and distortion via structured communication protocols such as face-to-face and written sign-out that use mnemonics and standardised templates, interactive questioning and distraction-free environments.1

These efforts have been fruitful. Interventions that bundle these practices have yielded improvements in educational and clinical outcomes.3 Yet, while these protocols improve safety, handovers still remain an important source of medical error and potential harm to patients. Accordingly, we must now choose how best to identify strategies that improve upon these first-generation interventions. In our view, since handovers...

‘The Problem with...’ series covers controversial topics related to efforts to improve healthcare quality, including widely recommended, but deceptively difficult strategies for improvement and pervasive problems that seem to resist solution. The series is overseen by Ken Catchpole (Guest Editor) and Kaveh Shojania (Editor-in-Chief).

Seminal reports that launched the modern field of patient safety highlighted the importance of learning from critical incidents.1 2 Since then, incident reporting systems have become one of the most widespread safety improvement strategies in healthcare, both within individual organisations and across entire healthcare systems.3

There are some strong examples of learning and improvement following serious patient safety incidents.4 5 But major disasters have also revealed widespread failures to understand and respond to reported safety incidents.6 7 Between these two extremes exists a range of frustrations and confusions...

Background

Shift change handoffs are known to be a point of vulnerability in the quality, safety and outcomes of healthcare. Despite numerous efforts to improve handoff reliability, few interventions have produced lasting change. Although the opportunity to ask questions during patient handoff has been required by some regulatory bodies, the function of questions during handoff has been less well explored and understood.

Objective

To investigate questions and the functions they serve in nursing and medicine handoffs.

Research design

Qualitative thematic analysis based on audio recordings of nurse-to-nurse, medical resident-to-resident and surgical intern-to-intern handoffs.

Subjects

Twenty-seven nurse handoff dyads and 18 medical resident and surgical intern handoff dyads at one VA Medical Center.

Results

Our analysis revealed that the vast majority of questions were asked by the Incoming Providers. Although topics varied widely, the bulk of Incoming Provider questions requested information that would best help them understand individual patient conditions and plan accordingly. Other question types sought consensus on clinical reasoning or framing and alignment between the two professionals.

Conclusions

Handoffs are a type of socially constructed work. Questions emerge with some frequency in virtually all handoffs but not in a linear or predictable way. Instead, they arise in the moment, as necessary, and without preplanning. A checklist cannot model this process element because it is a static memory aid and questions occur in a relational context that is emergent. Studying the different functions of questions during end of shift handoffs provides insights into the interface between the technical context in which information is transferred and the social context in which meaning is created.

Background

Tools and procedures designed to improve end-of-shift handoffs through standardisation of processes and reliance on technology may miss contextually sensitive information about anticipated events that emerges during face-to-face handoff interactions. Such information, what we refer to as anticipatory management communication (AMC), is necessary to ensure timely and safe patient care, but has been little studied and understood.

Objective

To investigate AMC and the role it plays in nursing and medicine handoffs.

Research design

Qualitative thematic analysis based on audio recordings of nurse-to-nurse, medical resident-to-resident and surgical intern-to-intern handoffs.

Subjects

27 nurse handoff dyads and 18 medical resident and surgical intern handoff dyads at one VA Medical Center.

Results

Heads-up information was the most frequent type of AMC across all handoff dyads (N=257; 108 resident and 149 nursing). Indirect instructions AMC was used in a little over half the resident handoff dyads, but occurred in all nursing dyads (292 instances). Direct instructions AMC occurred in roughly equal proportion across all dyads but at a modest frequency (N=45; 28 resident and 17 nursing). Direct (if/then) contingency AMC occurred in resident handoffs more frequently than in nursing handoffs (N=32; 30 resident and 2 nursing).

Conclusions

The different frequencies for types of AMC likely reflect differences in how residents and nurses work and disparate professional cultures. But, verbal communication in both groups included important information unlikely to be captured in written handoff tools or the electronic medical record, underscoring the importance of direct communication to ensure safe handoffs.

One of the key recommendations of the Institute of Medicine's (IOM) report, To Err is Human, 15 years ago was for greater attention to incident reporting in healthcare, analogous to the role it has played in aviation and other high-risk industries. With the passage of time and maturation of the patient safety field, we conducted semistructured interviews with 11 international patient safety experts with knowledge of the US healthcare and meeting at least one of the following criteria: (1) involved in the development of the IOM's recommendations, (2) responsible for the design and/or implementation of national or regional incident reporting systems, (3) conducted research on patient safety/incident reporting at a national level. Five key challenges emerged to explain why incident reporting has not reached its potential: poor processing of incident reports (triaging, analysis, recommendations), inadequate engagement of doctors, insufficient subsequent visible action, inadequate funding and institutional support of incident reporting systems and inadequate usage of evolving health information technology. Leading patient safety experts acknowledge the current challenges of incident reports. The future of incident reporting lies in targeted incident reporting, effective triaging and robust analysis of the incident reports and meaningful engagement of doctors. Incident reporting must be coupled with visible, sustainable action and linkage of incident reports to the electronic health record. If the healthcare industry wants to learn from its mistakes, miss or near miss events, it will need to take incident reporting as seriously as the health budget.

Background

Timely delivery of antibiotics to febrile immunocompromised (F&I) paediatric patients in the emergency department (ED) and outpatient clinic reduces morbidity and mortality.

Objective

The aim of this quality improvement initiative was to increase the percentage of F&I patients who received antibiotics within goal in the clinic and ED from 25% to 90%.

Methods

Using the Model of Improvement, we performed Plan-Do-Study-Act cycles to design, test and implement high-reliability interventions to decrease time to antibiotics. Pre-arrival interventions were tested and implemented, followed by post-arrival interventions in the ED. Many processes were spread successfully to the outpatient clinic. The Chronic Care Model was used, in addition to active family engagement, to inform and improve processes.

Results

The study period was from January 2010 to January 2015. Pre-arrival planning improved our F&I time to antibiotics in the ED from 137 to 88 min. This was sustained until October 2012, when further interventions including a pre-arrival huddle decreased the median time to <50 min. Implementation of the various processes to the clinic delivery system increased the mean percentage of patients receiving antibiotics within 60 min to >90%. In September 2014, we implemented a rapid response team to improve reliable venous access in the ED, which increased our mean percentage of patients receiving timely antibiotics to its highest rate (95%).

Conclusions

This stepwise approach with pre-arrival planning using the Chronic Care Model, followed by standardisation of processes, created a sustainable improvement of timely antibiotic delivery in F&I patients.

Introduction

Patient participation in healthcare is recognised internationally as essential for consumer-centric, high-quality healthcare delivery. Its measurement as part of continuous quality improvement requires development of agreed standards and measurable indicators.

Aim

This systematic review sought to identify strategies to measure patient participation in healthcare and to report their reliability and validity. In the context of this review, patient participation was constructed as shared decision-making, acknowledging the patient as having critical knowledge regarding their own health and care needs and promoting self-care/autonomy.

Methods

Following a comprehensive search, studies reporting reliability or validity of an instrument used in a healthcare setting to measure patient participation, published in English between January 2004 and March 2014 were eligible for inclusion.

Results

From an initial search, which identified 1582 studies, 156 studies were retrieved and screened against inclusion criteria. Thirty-three studies reporting 24 patient participation measurement tools met inclusion criteria, and were critically appraised. The majority of studies were descriptive psychometric studies using prospective, cross-sectional designs. Almost all the tools completed by patients, family caregivers, observers or more than one stakeholder focused on aspects of patient–professional communication. Few tools designed for completion by patients or family caregivers provided valid and reliable measures of patient participation. There was low correlation between many of the tools and other measures of patient satisfaction.

Conclusion

Few reliable and valid tools for measurement of patient participation in healthcare have been recently developed. Of those reported in this review, the dyadic Observing Patient Involvement in Decision Making (dyadic-OPTION) tool presents the most promise for measuring core components of patient participation. There remains a need for further study into valid, reliable and feasible strategies for measuring patient participation as part of continuous quality improvement.

Background

The central line bundle to reduce central line-associated bloodstream infections (CLABSI) is widely regarded as one of the most evidence-based quality improvement (QI) interventions. Yet, two high-quality trials reached different conclusions about its effectiveness.

Objective

To assess the overall evidence on the effectiveness of the central line bundle and also to illustrate issues related to appraising the effectiveness of QI interventions.

Methods

We searched the English-language literature (MEDLINE to Sept 2014) for prospective evaluations of the central line bundle (hand hygiene, chlorhexidine skin antisepsis, maximum sterile barrier precautions, optimal catheter site selection, daily review of line necessity) on CLABSI. Mantel–Haenszel risk ratios were calculated using a random effects model. Risk of bias was assessed on five domains: comparability of subjects, definition of intervention, assessment of outcome, statistical analysis and co-interventions/heterogeneity. Strength of the evidence was assessed following the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach, a widely recommended framework for assessing the robustness of treatment effect and the likelihood of change as a result of future studies.

Results

Across 59 studies, the central line bundle effectively reduced CLABSI by 56% (relative risk 0.44 (95% CI 0.39 to 0.50)). Studies that assessed bundle compliance at the individual patient level reported slightly higher reductions than other studies. Considerable heterogeneity was present in most subgroups. Most studies had unclear or high risk of bias, with only six (10%) studies exhibiting low risk of bias on at least four domains without any high risk. In this subset of higher-quality studies, the reduction was 52% (95% CI 32% to 66%) without heterogeneity. Applying the GRADE framework, the overall strength of the evidence was low, but moderate in quality for the six high-quality studies. This rating is typically interpreted as meaning that further research is likely to have an important impact on our confidence in the effect estimate and may change the estimate.

Conclusions

That the central line bundle could receive only a moderate evidence rating may suggest that the GRADE framework, developed mostly for traditional clinical therapies, requires modification for QI interventions. GRADE does not distinguish prospective trials (eg, controlled before-after studies and interrupted time series) from lower-level observational studies. On the other hand, that the two highest quality studies reached different conclusions makes it difficult to conclude that future research would not change the effect estimate, especially given evidence of secular trends and the variability of co-interventions to ensure bundle compliance, which created heterogeneity across studies.

Patient participation can be seen as an end in and of itself, and it can be seen as a way to foster further goals like quality and safety in healthcare, adherence and cost-effectiveness. Wide-scale implementation of interventions to increase patient participation without having confidence in its measures means being unable to determine if implementation was successful or the desired outcome was achieved. Therefore, we were pleased to see a review of measures assessing patient participation in healthcare.

However, we have some major concerns about the conceptual approach, the method and the conclusions in the review by Phillips and colleagues.1

In our opinion, the presented conceptual model of patient participation is defined quite broadly. This makes it difficult to have it represented accurately by the search terms. In particular, shared decision-making (SDM) is defined as one of the ‘core requirements in patient participation’, but ‘shared decision-making’ is not...

We were very interested to read the article by Greig et al,1 which has identified how poorly non-technical skills appear in a review of 46 postgraduate curricula from all medical specialties. This is similar to work sponsored by the Academy of Medical Royal Colleges and carried out by the Royal College of Surgeons of Edinburgh (RCSEd) in conjunction with the NHS Institute of Innovation and Improvement2 which also demonstrated significant deficiency in identifying patient safety in general and non-technical skills in particular, as part of the requirement for any educational portfolio. This project also provided an online curriculum builder that could be customised for each medical specialty. There was, however, little uptake by medical educationalists in any specialty. We are, therefore, in complete agreement with the authors in their view that non-technical skills need to be explicitly taught within all medical curricula, along with much...

Thank you for the opportunity to respond to the letter to the editor from Geiger et al1 and discuss aspects of our systematic review.2

We acknowledge that the authors of the letter have made a substantial contribution to the body of knowledge of shared decision-making and its measurement. However, we highlight that the conceptual approach to patient participation in our systematic review was reflective of the broad nature of patient participation. As stated in the background,2 the terms ‘patient participation’ and ‘patient centredness’ are often used synonymously. There are a number of concepts that inform patient participation/patient-centeredness. For example, de Silva3 identified almost 40 key components to patient-centred care, 19 behaviours and 19 sub-component themes, shared decisions being just one of these concepts.

We purposely did not consider tools that focused solely on shared decision-making in isolation from other concepts encapsulated...

We thank Professor Youngson et al1 for their interest in our work2 and their comments calling for greater standardisation in medical non-technical skills (NTS) teaching.

We are pleased that Professor Youngson agrees with our conclusion about the need for better cooperation and communication between specialties on how such training and assessment should be carried out. We are also delighted to acknowledge the important work being carried out by the Royal College of Surgeons (Edinburgh) (RCSEd) and the University of Aberdeen on the development of Non-Technical Skills for Surgeons (NOTSS), and are of course aware of the paper by Crossley et al.3

Although much excellent work has been done, we still maintain that more might be done to integrate these developments into the formal training curricula across all medical specialties. We note that, when published in 2011, the paper by Crossley et al, which...

Macrae highlights well-discussed challenges of using safety incident reporting systems as a source of learning and improvement in healthcare.1 Our research group has analysed over 50 000 free-text reports from primary care submitted to the England and Wales National Reporting and Learning System, and developed a mixed methods approach to identify learning from these reports.2

We agree that simply aiming for a greater number of reports to remedy problems arising from under-reporting is not desirable. There is, however, an opportunity to target specific discipline or professional groups to stimulate a culture of reporting, and efforts in anaesthetics have been commendable. From our analysis of incidents involving children in primary care3 4 we would advocate initiatives that promote reporting across multiple sectors, not least patient-reporting, at local and national levels. Further, encouraging reports about specific safety incident types and specific patient groups (eg,...

Williams, Cooper and Carson-Stevens1 highlight some advanced approaches to analysing safety incident reports that can generate valuable insights into the causes of common events, and can help identify and prioritise topics for more focused conversations, investigations and improvement actions. However, in many healthcare settings, the focus on collecting and analysing large quantities of incident data continues to distract attention from the social, collaborative and participative work that is required to learn from safety incidents. Learning from safety incidents is by necessity a contact sport: it happens when people actively reflect on their own practices and collaboratively work together to investigate and reorganise systems.2 Incident reporting systems provide a continual stream of concrete events around which rapid cycles of investigation and improvement can be routinely organised. These practical improvement activities are the ultimate purpose of incident reporting, and in many cases these activities can—and should—take place...

December 17, 2015 | We might spend our entire working lives striving to become better colleagues and leaders and more effective team members. Dr. Neil Baker works with health care organizations to enhance leadership and team impact; he offers effective ways to interrupt unproductive “reactive” patterns to get back on the right track.