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Preview: International Journal for Quality in Health Care - current issue

International Journal for Quality in Health Care Current Issue





Published: Thu, 05 Oct 2017 00:00:00 GMT

Last Build Date: Thu, 05 Oct 2017 10:51:44 GMT

 






Physicians’ and pharmacists’ perceptions on real-time drug utilization review system: a nationwide survey

2017-10-05

Abstract
Objective
To identify healthcare providers’ experience and satisfaction for the drug utilization review (DUR) system, their impact on prescription changes following alerts, and difficulties experienced in the system by surveying primary healthcare centers and pharmacies.
Design
A cross-sectional nationwide survey.
Setting and participants
Approximately 2000 institutions were selected for the survey by a simple random sampling of nationwide primary healthcare centers and community pharmacy approximately practices, and 358 replied.
Main outcomes measures
The questionnaire included questions on experience and recognition of DUR alerts, personal attitude and respondents’ biographical information. Space was included for respondents to suggest improvements of the DUR system.
Results
The DUR system scored 71.5 out of 100 points for satisfaction by physicians and pharmacists, who reported that the alerts prevent medication-related errors; most respondents (96.6%) received the alerts. Several respondents (10.9%) replied that they prescribe or dispense prescriptions as they are without following the alerts. Physicians (adjusted odds ratio, 8.334; 95% confidence interval, 3.449–20.139) are more likely to change the prescription than pharmacists and persons with alert experience (4.605; 1.080–19.638). However, current practice in metropolitan areas (0.478; 0.228–1.000) and frequent alerts regarding co-administration incompatibilities within prescriptions (0.135; 0.031–0.589) negatively influence adherence to DUR alerts.
Conclusions
Although most surveyed physicians and pharmacists receive the alerts, some do not or reported that they would not follow the alerts. To increase adherence, the DUR system should be improved to ensure a preferential and intensive approach to detecting potentially high-risk drug combinations.



The role of patient perception of crowding in the determination of real-time patient satisfaction at Emergency Department

2017-10-05

Abstract
Objective
To evaluate the associations between real-time overall patient satisfaction and Emergency Department (ED) crowding as determined by patient percepton and crowding estimation tool score in a high-volume ED.
Design
A prospective observational study.
Setting
A tertiary acute hospital ED and a Level 1 trauma center.
Participants
ED patients.
Intervention(s)
Crowding status was measured by two crowding tools [National Emergency Department Overcrowding Scale (NEDOCS) and Severely overcrowded–Overcrowded–Not overcrowded Estimation Tool (SONET)] and patient perception of crowding surveys administered at discharge.
Main outcome measure(s)
ED crowding and patient real-time satisfaction.
Results
From 29 November 2015 through 11 January 2016, we enrolled 1345 participants. We observed considerable agreement between the NEDOCS and SONET assessment of ED crowding (bias = 0.22; 95% limits of agreement (LOAs): −1.67, 2.12). However, agreement was more variable between patient perceptions of ED crowding with NEDOCS (bias = 0.62; 95% LOA: −5.85, 7.09) and SONET (bias = 0.40; 95% LOA: −5.81, 6.61). Compared to not overcrowded, there were overall inverse associations between ED overcrowding and patient satisfaction (Patient perception OR = 0.49, 95% confidence limit (CL): 0.38, 0.63; NEDOCS OR = 0.78, 95% CL: 0.65, 0.95; SONET OR = 0.82, 95% CL: 0.69, 0.98).
Conclusions
While heterogeneity exists in the degree of agreement between objective and patient perceived assessments of ED crowding, in our study we observed that higher degrees of ED crowding at admission might be associated with lower real-time patient satisfaction.



Avoidable emergency department visits: a starting point

2017-08-31

Abstract
Objective
To better characterize and understand the nature of a very conservative definition of ‘avoidable’ emergency department (ED) visits in the United States to provide policymakers insight into what interventions can target non-urgent ED visits.
Design/setting
We performed a retrospective analysis of a very conservative definition of ‘avoidable’ ED visits using data from the National Hospital Ambulatory Medical Care Survey from 2005 to 2011.
Participants
We examined a total of 115 081 records, representing 424 million ED visits made by patients aged 18–64 years who were seen in the ED and discharged home.
Main outcome measures
We defined ‘avoidable’ as ED visits that did not require any diagnostic or screening services, procedures or medications, and were discharged home.
Results
In total, 3.3% (95% CI: 3.0–3.7) of all ED visits were ‘avoidable.’ The top five chief complaints included toothache, back pain, headache, other symptoms/problems related to psychosis and throat soreness. Alcohol abuse, dental disorders and depressive disorders were among the top three ICD-9 discharge diagnoses. Alcohol-related disorders and mood disorders accounted for 6.8% (95% CI: 5.7–8.0) of avoidable visits, and dental disorders accounted for 3.9% (95% CI: 3.0–4.8) of CCS-grouped discharge diagnoses.
Conclusions
A significant number of ‘avoidable’ ED visits were for mental health and dental conditions, which the ED is not fully equipped to treat. Our findings provide a better understanding of what policy initiatives could potentially reduce these ‘avoidable’ ED visits to address the gaps in our healthcare system, such as increased access to mental health and dental care.



Compliance with accreditation and recommended hospital care—a Danish nationwide population-based study

2017-08-22

Abstract
Objective
To examine the association between compliance with accreditation and recommended hospital care.
Design
A Danish nationwide population-based follow-up study based on data from six national, clinical quality registries between November 2009 and December 2012.
Setting
Public, non-psychiatric Danish hospitals.
Participants
Patients with acute stroke, chronic obstructive pulmonary disease, diabetes, heart failure, hip fracture and bleeding/perforated ulcers.
Interventions
All hospitals were accredited by the first version of The Danish Healthcare Quality Programme. Compliance with accreditation was defined by level of accreditation awarded the hospital after an announced onsite survey; hence, hospitals were either fully (n = 11) or partially accredited (n = 20).
Main Outcome Measures
Recommended hospital care included 48 process performance measures reflecting recommendations from clinical guidelines. We assessed recommended hospital care as fulfilment of the measures individually and as an all-or-none composite score.
Results
In total 449 248 processes of care were included corresponding to 68 780 patient pathways. Patients at fully accredited hospitals had a significantly higher probability of receiving care according to clinical guideline recommendations than patients at partially accredited hospitals across conditions (individual measure: adjusted odds ratio (OR) = 1.20, 95% CI: 1.01–1.43, all-or-none: adjusted OR = 1.27, 95% CI: 1.02–1.58). For five of the six included conditions there were an association; the pattern appeared particular strong among patients with acute stroke and hip fracture (all-or-none; acute stroke: adjusted OR = 1.39, 95% CI: 1.05–1.83, hip fracture: adjusted OR = 1.57, 95% CI: 1.00–2.49).
Conclusion
High compliance with accreditation standards was associated with a higher level of evidence-based hospital care in Danish hospitals.



A multi-state, multi-site, multi-sector healthcare improvement model: implementing evidence for practice

2017-08-14

Abstract
Quality problem or issue
Healthcare is complex and we know that evidence takes nearly 20 years to find its way into clinical practice.
Initial assessment
The slow process of translating research points to the need for effective translational research models to ensure patient care quality and safety are not compromised by such an epistemic failure.
Choice of solution
Our model to achieve reasonably rapid and enduring improvements to clinical care draws on that developed and promulgated by the Institute for Healthcare Improvement in the United States of America model as well as that developed by the Johns Hopkins Quality and Safety Group known as the Translating Research into Practice implementation model.
Implementation
The core principle of our hybrid model was to engage those most likely to be affected by the changes being introduced through a series of face-to-face and web-enabled meetings that act both as drivers of information but also as a means of engaging all stakeholders across the healthcare system involved in the change towards their pre-established goals.
Evaluation
The model was piloted on the focused topic of the management of inadvertent perioperative hypothermia across nine hospitals within Australia (four sites in Victoria, three sites in New South Wales and two sites in Queensland). Improvement in management of hypothermia in these patients was achieved and sustained over time.
Lessons learned
Our model aims to engage the hearts and minds of healthcare clinicians, and others in order to empower them to make the necessary improvements to enhance patient care quality and safety.



The patient-centered medical home: a reality for HIV care in Nigeria

2017-08-09

Abstract
Objective
HIV care delivery in resource-limited settings (RLS) may serve as a paradigm for chronic disease care, but comprehensive measurement frameworks are lacking. Our objective was to adapt the patient-centered medical home (PCMH) framework for use in RLS, and evaluate the performance of HIV treatment programs within this framework.
Design and setting
Cross-sectional survey administered within the AIDS Prevention Initiative in Nigeria (APIN) network.
Participants
Medical directors at APIN clinics.
Main outcome measures
We adapted the 2011 US National Committee on Quality Assurance's PCMH standard to develop a survey measuring five domains of HIV care: (i) enhancing access and continuity, (ii) identifying and managing patient populations, (iii) planning and managing care, (iv) promoting self-care and support and (v) measuring and improving performance.
Results
Thirty-three of 36 clinics completed the survey. Most were public (73%) and urban/semi-urban (64%); 52% had >500 patients in care. On a 0–100 scale, clinics scored highest in self-care and support, 91% (63–100%); managing patient populations, 80% (72–81%) and improving performance, 72% (44–78%). Clinics scored lowest with the most variability in planning/managing care, 65% (22–89%), and access and continuity, 61% (33–80%). Average score across all domains was 72% (58–81%).
Conclusions
Our findings suggest that the modified PCMH tool is feasible, and likely has sufficient performance variation to discriminate among clinics. Consistent with extant literature, clinics showed greatest room for improvement on access and continuity, supporting the tool's face validity. The modified PCMH tool may provide a powerful framework for evaluating chronic HIV care in RLS.



Attitudes towards accreditation among hospital employees in Denmark: a cross-sectional survey

2017-08-09

Abstract
Objective
To evaluate attitudes towards accreditation and the Danish Quality Model (DDKM) among hospital employees in Denmark. Negative attitudes led the Danish Government to abolish accreditation in 2015.
Design
A cross-sectional survey was carried out via web-based questionnaire.
Setting
All hospital managers, quality improvement staff (quality managers and employees), and hospital surveyors in Denmark; and clinicians (doctors and nurses) within nine selected specialties.
Participants
Overall response rate was 29% with 5055 of 17 646 valid responses included in the data analysis. The response rate was 82% (5055/6188) among respondents who clicked on the link in the mail containing the questionnaire.
Methods
A short questionnaire was designed using a 7-point Likert scale ranging from 1 ‘strongly disagree’ to 7 ‘strongly agree’. To compare mean values between respondent groups, regression analysis using dummy coding of respondent groups and calculation of standardized mean difference effect sizes were performed.
Results
Overall attitudes were supportive, with physicians more skeptical. There were different patterns of attitudes in the five Danish regions and between medical professions. A small group of physicians was extremely negative.
Conclusion
Clinical attitudes are important, and can affect Government decisions. On the basis of our study, future attention should be paid to attitudes towards accreditation (and attitudes towards other means of quality improvement). Attitudes may reflect political agendas and impede the take-up of improvement programs, cause their demise, or reduce their effectiveness.



What works in implementation of integrated care programs for older adults with complex needs? A realist review

2017-08-09

Abstract
Purpose
A realist review of the evaluative evidence was conducted on integrated care (IC) programs for older adults to identify key processes that lead to the success or failure of these programs in achieving outcomes such as reduced healthcare utilization, improved patient health, and improved patient and caregiver experience.
Data sources
International academic literature was searched in 12 indexed, electronic databases and gray literature through internet searches, to identify evaluative studies.
Study selection
Inclusion criteria included evaluative literature on integrated, long-stay health and social care programs, published between January 1980 and July 2015, in English.
Data extraction
Data were extracted on the study purpose, period, setting, design, population, sample size, outcomes, and study results, as well as explanations of mechanisms and contextual factors influencing outcomes.
Results of data synthesis
A total of 65 articles, representing 28 IC programs, were included in the review. Two context-mechanism-outcome configurations (CMOcs) were identified: (i) trusting multidisciplinary team relationships and (ii) provider commitment to and understanding of the model. Contextual factors such as strong leadership that sets clear goals and establishes an organizational culture in support of the program, along with joint governance structures, supported team collaboration and subsequent successful implementation. Furthermore, time to build an infrastructure to implement and flexibility in implementation, emerged as key processes instrumental to success of these programs.
Conclusions
This review included a wide range of international evidence, and identified key processes for successful implementation of IC programs that should be considered by program planners, leaders and evaluators.



Are children presenting with non-IMCI complaints at greater risk for suboptimal screening? An analysis of outpatient visits in Afghanistan

2017-07-28

Abstract
Objective
To determine if children presenting without complaints related to the Integrated Management of Childhood Illness (IMCI) are at greater risk for suboptimal screening for IMCI conditions
Design
Cross-sectional study.
Setting
Thirty-three provinces in Afghanistan.
Participants
Observation of 3072 sick child visits selected by systematic random sampling.
Main outcome measure(s)
A 10 point IMCI assessment index.
Results
One hundred and thirty-one (4.3%) of the 3072 sick child visits involved no IMCI-related complaints. The mean assessment index for all sick child visits was 4.81 (SD 2.41). Visits involving any IMCI-related complaint were associated with a 1.02 point higher mean assessment index than those without IMCI-related complaints (95% CI, 0.52–1.53; P < 0.001). After adjusting for relevant covariates including patient age, caretaker gender, provider type, provider gender, provider IMCI training status and IMCI guideline availability, we found that children with IMCI-related presenting complaints had a significantly better quality of IMCI screening, than those without IMCI presenting complaints (by 0.75 points; 95% CI, 0.25–1.26; P = 0.003)
Conclusions
Our study indicates that children with non-IMCI presenting complaints are at greater risk of suboptimal screening compared to children with IMCI-related presenting complaints. The premise of IMCI is to routinely screen all children for conditions responsible for the major burden of childhood disease in countries like Afghanistan. The study illustrates an important finding that facility and provider capacity needs to be improved, particularly during training, supervision and guideline dissemination to ensure that all children receive routine screening for common IMCI conditions.



A comparison of in-hospital acute myocardial infarction management between Portugal and the United States: 2000–2010

2017-07-28

Abstract
Objective
To compare healthcare in acute myocardial infarction (AMI) treatment between contrasting health systems using comparable representative data from Europe and USA.
Design
Repeated cross-sectional retrospective cohort study.
Setting
Acute care hospitals in Portugal and USA during 2000–2010.
Participants
Adults discharged with AMI.
Interventions
Coronary revascularizations procedures (percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG) surgery).
Main Outcome Measures
In-hospital mortality and length of stay.
Results
We identified 1 566 601 AMI hospitalizations. Relative to the USA, more hospitalizations in Portugal presented with elevated ST-segment, and fewer had documented comorbidities. Age-sex-adjusted AMI hospitalization rates decreased in USA but increased in Portugal. Crude procedure rates were generally lower in Portugal (PCI: 44% vs. 47%; CABG: 2% vs. 9%, 2010) but only CABG rates differed significantly after standardization. PCI use increased annually in both countries but CABG decreased only in the USA (USA: 0.95 [0.94, 0.95], Portugal: 1.04 [1.02, 1.07], odds ratios). Both countries observed annual decreases in risk-adjusted mortality (USA: 0.97 [0.965, 0.969]; Portugal: 0.99 [0.979, 0.991], hazard ratios). While between-hospital variability in procedure use was larger in USA, the risk of dying in a high relative to a low mortality hospital (hospitals in percentiles 95 and 5) was 2.65 in Portugal when in USA was only 1.03.
Conclusions
Although in-hospital mortality due to an AMI improved in both countries, patient management in USA seems more effective and alarming disparities in quality of care across hospitals are more likely to exist in Portugal.



Evaluating the impact of accreditation on Brazilian healthcare organizations: A quantitative study

2017-07-28

Abstract
Objective
The aim of this study was to evaluate the impact of accreditation programs on Brazilian healthcare organizations.
Design
A web-based questionnaire survey was undertaken between February and May 2016.
Setting
Healthcare organizations from the Federal District and from 18 Brazilian states.
Participants
The quality managers of 141 Brazilian healthcare organizations were the main respondents of the study.
Intervention
The questionnaire was applied to not accredited and accredited organizations.
Main Outcome Measures
The main outcome measures were patient safety activities, quality management activities, planning activities—policies and strategies, patient involvement, involvement of professionals in the quality programs, monitoring of patient safety goals, organizational impact and financial impacts.
Results
The study identified 13 organizational impacts of accreditation. There was evidence of a significant and moderate correlation between the status of accreditation and patient safety activities, quality management activities, planning activities—policies and strategies, and involvement of professionals in the quality programs. The correlation between accreditation status and patient involvement was significant but weak, suggesting that this issue should be treated with a specific policy. The impact of accreditation on the financial results was not confirmed as relevant; however, the need for investment in the planning stage was validated.
Conclusions
The impact of accreditation is mainly related to internal processes, culture, training, institutional image and competitive differentiation.



Reporting of medication administration errors by nurses in South Korean hospitals

2017-07-28

Abstract
Objective
To identify differences in what nurses consider as medication administration errors, to examine their willingness to report these errors and to identify barriers to reporting medication errors by hospital type.
Design
Cross-sectional, descriptive design. The questionnaire comprised six medication administration error scenarios and items related to the reasons for not reporting medication errors.
Setting
Two tertiary and three general hospitals in a metropolitan area, and five general hospitals in K province, in South Korea.
Participants
Registered nurses working at tertiary and general hospitals in South Korea (n = 467).
Main outcome measures
Consideration of medication administration errors, intention to report medication errors and reasoning for not file an incident report.
Results
There were no significant differences in what nurses considered as medication administration errors between nurses working different in hospital types. The rate of incident reporting was very low; it ranged from 6.3% to 29.9%, regardless of hospital type. Korean nurses were more likely to report an error to a physician than file an incident report. The primary reason for not reporting medication errors was fear of the negative consequences of reporting the error and subsequent legal action.
Conclusions
The rate of filing an incident report among nurses was very low, regardless of hospital type or whether nurses perceived the incident as a medication administration error. These results may have significant implications for improving medication safety in hospitals, and more efforts are needed at the organizational level to improve incident reporting by nurses.



A qualitative study of sign-out processes between primary and on-call residents: relationships in information exchange, responsibility and accountability

2017-07-18

Abstract
Objective
To review a quality improvement event on the process of sign-outs between the primary and on-call residents.
Design
A retrospective qualitative study using semi-structured interviews.
Setting
A tertiary academic medical center in Singapore with 283 inpatient Medicine beds served by 28 consultants, 29 registrars, 45 residents and 30 interns during the day but 5 residents and 3 interns at night.
Participants
Residents, registrars and consultants.
Intervention
Quality improvement event on sign-out.
Main outcome
Effectiveness of sign-out comprises exchange of patient information, professional responsibility and task accountability.
Results
The following process of sign-outs was noted. Primary teams were accountable to the on-call resident by selecting at-risk patients and preparing contingency plans for sign-out. Structured information exchanged included patient history, active problems and plans of care. On-call residents took ownership of at-risk patients by actively asking questions during sign-out and reporting back the agreed care plan. On-call residents were accountable to the primary team by reporting back at-risk patients the next day.
Conclusion
A structured information exchange at sign-out increased the on-call resident's ability to care for at-risk patients when it was supported by two-way transfers of responsibility and accountability.



Burnout syndrome among non-consultant hospital doctors in Ireland: relationship with self-reported patient care

2017-07-18

Abstract
Objective
Intensive workload and limited training opportunities for Irish non-consultant hospital doctors (NCHDs) has a negative effect on their health and well-being, and can result in burnout. Burnout affects physician performance and can lead to medical errors. This study examined the prevalence of burnout syndrome among Irish NCHDs and its association with self-reported medical error and poor quality of patient care.
Methods
A cross-sectional quantitative survey-based design.
Setting
All teaching hospitals affiliated with University College Cork.
Participants
NCHDs of all grades and specialties.
Intervention(s)
The following instruments were completed by all participants: Maslach Burnout Inventory-Human Service Survey (MBI-HSS), assessing three categories of burnout syndrome: Emotional exhaustion (EE), Personal Achievement (PA) and Depersonalization (DP); questions related to self-reported medical errors/poor patient care quality and socio-demographic information.
Main outcome measure(s)
Self-reported measures of burnout and poor quality of patient care.
Results
Prevalence of burnout among physicians (n = 265) was 26.4%. There was a significant gender difference for EE and DP, but none for PA. A positive weak correlation was observed between EE and DP with medical error or poor patient care. A negative association was reported between PA and medical error and reduced quality of patient care.
Conclusions
Burnout is prevalent among NCHDs in Ireland. Burnout syndrome is associated with self-reported medical error and quality of care in this sample population. Measures need to be taken to address this issue, with a view to protecting health of NCHDs and maintaining quality of patient care.



Hospital survey on patient safety culture (HSOPS): variability of scoring strategies

2017-07-18

Abstract
Objective
To assess the variability of safety culture dimension scores and their associated rankings depending on three different scoring strategies using the Hospital Survey On Patient Safety Culture (HSOPS).
Design
Cross-sectional study using a self-administered questionnaire.
Setting
The study was conducted in an 1836-bed acute-care French university hospital with an annual volume of 135 999 stays, between April 2013 and November 2014.
Participants
All caregivers and technical-administrative staff with at least 6 months of employment, spending at least half of their working time in the hospital, were asked to participate.
Intervention
None.
Main outcome measure
The variability of the HSOPS results using three different scoring methods: the percentage of positive responses recommended by the Agency for Healthcare Research and Quality, the averaged individual means and the averaged individual sums.
Results
The response rate was 78.6% (n = 3978). The percentage of positive responses resulted in lower scores compared to averaged individual means and averaged individual sums in the six least developed dimensions, and gave more widely spread scores and greater 95CIs in the six most developed dimensions. Department rankings also varied greatly depending on the scoring methods.
Conclusion
The values of the HSOPS scores and their corresponding rankings greatly depended on the computation method. This finding shows how important it is to agree on the use of the same scoring strategies, before broadly comparing results within and across organizations.



Inappropriate hospital days of a tertiary hospital in Shanghai, China

2017-07-18

Abstract
Objective
This study aims to evaluate the prevalence of inappropriate hospital stays in a tertiary hospital in Shanghai, identify the causes for the inappropriateness and analyze the predictors.
Design
A retrospective review of medical records.
Setting
The cardiology and the orthopedics departments of a tertiary hospital in Shanghai, China.
Participants
About 806 patients discharged from the cardiology or the orthopedics department of a tertiary hospital from March 2013 to February 2014.
Interventions
Two reviewers audited 8396 hospital days of the cardiology department (n = 3606) and the orthopedics department (n = 4790) by adopting the Chinese Version of the Appropriateness Evaluation Protocol. Univariate and multivariate analysis were adopted to identify the predictors of higher levels of inappropriateness produced by internal causes.
Main outcome measure
The prevalence of inappropriate hospital days.
Results
It was found that 910 (25.2%) and 1940 (40.5%) hospital days were judged to be inappropriate in the cardiology and the orthopedics departments, respectively; and 753 (20.9%) and 1585 (33.1%) of these inappropriate hospital days were due to internal reasons, respectively. Awaiting tests, surgery or discharge were determined to constitute the main causes of inappropriateness for both departments. The predictors of higher levels of inappropriateness in the cardiology department were younger age, self-pay, outpatient admission and inappropriate admission. Self-pay, surgical and/or first-time admission patients exhibited the highest levels of inappropriateness in the orthopedics department.
Conclusions
The rates of inappropriateness in the involved departments were relatively high. Further interventions should be designed and implemented, accordingly.



The degree of severity and trends in hospital standardized mortality ratios in Japan between 2008 and 2012: a retrospective observational study

2017-07-18

Abstract
Objectives
Hospital standardized mortality ratio (HSMR), an indicator that adjusts hospital mortality for case-mix differences, is used as a hospital performance measure. The aim of this study is to build a new HSMR model in Japan and examine HSMR trends according to the degree of severity.
Design
Observational retrospective study.
Settings
Data from the Japanese Administrative Database.
Participants
A total of 3 813 492 admissions from 278 Japanese acute-care hospitals were extracted from the database (patients between 2008 and 2012, from July to December in each year).
Main Outcome Measures
We estimated the probability of in-hospital death by fitting a logistic regression model, and assessed the performance of the models with the c-index. In each year, HSMRs were obtained by calculating the ratio of the number of observed deaths to the number of expected deaths. The HSMR trends, including trends in comorbidity subgroups defined by the Charlson comorbidity index, were analysed.
Results
The c-index value was 0.871 for the HSMR model. The HSMR followed a constant decreasing trend over time; it fell by 18.8% from 110.3 in 2008 to 91.5 in 2012. The reduction in HSMR was not present in the severe comorbidity group, while the reduction trend was observed in the mild comorbidity group.
Conclusions
Our model demonstrated excellent discrimination without detailed clinical data. The Japanese HSMR followed a constant decreased trend, while the reduction trend was not present in the severe patients. Our study implies the need to consider severe patients for assessing hospital quality by HSMR.



Using an online quiz-based reinforcement system to teach healthcare quality and patient safety and care transitions at the University of California

2017-07-18

Abstract
Quality issue
Implementing quality improvement (QI) education during clinical training is challenging due to time constraints and inadequate faculty development in these areas.
Initial assessment
Quiz-based reinforcement systems show promise in fostering active engagement, collaboration, healthy competition and real-time formative feedback, although further research on their effectiveness is required.
Choice of solution
An online quiz-based reinforcement system to increase resident and faculty knowledge in QI, patient safety and care transitions.
Implementation
Experts in QI and educational assessment at the 5 University of California medical campuses developed a course comprised of 3 quizzes on Introduction to QI, Patient Safety and Care Transitions. Each quiz contained 20 questions and utilized an online educational quiz-based reinforcement system that leveraged spaced learning.
Evaluation
Approximately 500 learners completed the course (completion rate 66–86%). Knowledge acquisition scores for all quizzes increased after completion: Introduction to QI (35–73%), Patient Safety (58–95%), and Care Transitions (66–90%). Learners reported that the quiz-based system was an effective teaching modality and preferred this type of education to classroom-based lectures. Suggestions for improvement included reducing frequency of presentation of questions and utilizing more questions that test learners on application of knowledge instead of knowledge acquisition.
Lessons learned
A multi-campus online quiz-based reinforcement system to train residents in QI, patient safety and care transitions was feasible, acceptable, and increased knowledge. The course may be best utilized to supplement classroom-based and experiential curricula, along with increased attention to optimizing frequency of presentation of questions and enhancing application skills.



Conceptualizing and assessing improvement capability: a review

2017-07-18

Abstract
Purpose
The literature is reviewed to examine how ‘improvement capability’ is conceptualized and assessed and to identify future areas for research.
Data sources
An iterative and systematic search of the literature was carried out across all sectors including healthcare. The search was limited to literature written in English.
Data extraction
The study identifies and analyses 70 instruments and frameworks for assessing or measuring improvement capability. Information about the source of the instruments, the sectors in which they were developed or used, the measurement constructs or domains they employ, and how they were tested was extracted.
Results of data synthesis
The instruments and framework constructs are very heterogeneous, demonstrating the ambiguity of improvement capability as a concept, and the difficulties involved in its operationalisation. Two-thirds of the instruments and frameworks have been subject to tests of reliability and half to tests of validity. Many instruments have little apparent theoretical basis and do not seem to have been used widely.
Conclusion
The assessment and development of improvement capability needs clearer and more consistent conceptual and terminological definition, used consistently across disciplines and sectors. There is scope to learn from existing instruments and frameworks, and this study proposes a synthetic framework of eight dimensions of improvement capability. Future instruments need robust testing for reliability and validity. This study contributes to practice and research by presenting the first review of the literature on improvement capability across all sectors including healthcare.



Researching safety culture: deliberative dialogue with a restorative lens

2017-07-18

Abstract
Safety culture is a key component of patient safety. Many patient safety strategies in health care have been adapted from high-reliability organizations (HRO) such as aviation. However, to date, attempts to transform the cultures of health care settings through HRO approaches have had mixed results. We propose a methodological approach for safety culture research, which integrates the theory and practice of restoration science with the principles and methods of deliberative dialogue to support active engagement in critical reflection and collective debate. Our aim is to describe how these two innovative approaches in health services research can be used together to provide a comprehensive effective method to study and implement change in safety culture. Restorative research in health care integrates socio-ecological theory of complex adaptive systems concepts with collaborative, place-sensitive study of local practice contexts. Deliberative dialogue brings together all stakeholders to collectively develop solutions on an issue to facilitate change. Together these approaches can be used to actively engage people in the study of safety culture to gain a better understanding of its elements. More importantly, we argue that the synergistic use of these approaches offers enhanced potential to move health care professionals towards actionable strategies to improve patient safety within today's complex health care systems.