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Annals of internal medicine 03/2013; 158(5 Pt 1):350-2. · 16.73 Impact Factor
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Paul G Shekelle,
Peter J Pronovost, Robert M Wachter,
Kathryn M McDonald,
Karen Schoelles,
Sydney M Dy,
Kaveh Shojania,
James T Reston,
Alyce S Adams,
Peter B Angood, [......],
Richard Lilford,
Kathleen N Lohr,
Gregg S Meyer,
Marlene R Miller,
Duncan V Neuhauser,
Gery Ryan,
Sanjay Saint,
Stephen M Shortell,
David P Stevens,
Kieran Walshe
Annals of internal medicine 03/2013; 158(5 Pt 2):365-8. · 16.73 Impact Factor
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ABSTRACT: BACKGROUND: Academic hospitalist groups (AHGs) are often expected to excel in multiple domains: quality improvement, patient safety, education, research, administration, and clinical care. To be successful, AHGs must develop strategies to balance their energies, resources, and performance. The balanced scorecard (BSC) is a strategic management system that enables organizations to translate their mission and vision into specific objectives and metrics across multiple domains. To date, no hospitalist group has reported on BSC implementation. We set out to develop a BSC as part of a strategic planning initiative. METHODS: Based on a needs assessment of the University of California, San Francisco, Division of Hospital Medicine, mission and vision statements were developed. We engaged representative faculty to develop strategic objectives and determine performance metrics across 4 BSC perspectives. RESULTS: There were 41 metrics identified, and 16 were chosen for the initial BSC. It allowed us to achieve several goals: 1) present a broad view of performance, 2) create transparency and accountability, 3) communicate goals and engage faculty, and 4) ensure we use data to guide strategic decisions. Several lessons were learned, including the need to build faculty consensus, establish metrics with reliable measureable data, and the power of the BSC to drive goals across the division. CONCLUSIONS: We successfully developed and implemented a BSC in an AHG as part of a strategic planning initiative. The BSC has been instrumental in allowing us to achieve balanced success in multiple domains. Academic groups should consider employing the BSC as it allows for a data-driven strategic planning and assessment process. Journal of Hospital Medicine 2013. © 2013 Society of Hospital Medicine.
Journal of Hospital Medicine 01/2013; · 1.40 Impact Factor
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ABSTRACT: Despite widespread emphasis on promoting 'assertive communication' by care givers as essential to patient-safety-improvement efforts, little is known about when and how clinicians speak up to address safety concerns. In this cross-sectional study, the authors use a new measure of speaking up to begin exploring this issue in maternity care.
The authors developed a scenario-based measure of clinician's assessment of potential harm and likelihood of speaking up in response to perceived harm. The authors embedded this scale in a survey with measures of safety climate, teamwork climate, disruptive behaviour, work stress, and personality traits of bravery and assertiveness. The survey was distributed to all registered nurses and obstetricians practising in two US Labour & Delivery units.
The response rate was 54% (125 of 230 potential respondents). Respondents were experienced clinicians (13.7±11 years in specialty). A higher perception of harm, respondent role, specialty experience and site predicted the likelihood of speaking up when controlling for bravery and assertiveness. Physicians rated potential harm in common clinical scenarios lower than nurses did (7.5 vs 8.4 on 2-10 scale; p<0.001). Some participants (12%) indicated they were unlikely to speak up, despite perceiving a high potential for harm in certain situations.
This exploratory study found that nurses and physicians differed in their harm ratings, and harm rating was a predictor of speaking up. This may partially explain persistent discrepancies between physicians and nurses in teamwork climate scores. Differing assessments of potential harms inherent in everyday practice may be a target for teamwork intervention in maternity care.
BMJ quality & safety 09/2012; 21(9):791-9.
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ABSTRACT: Unsolicited web-based comments by patients regarding their healthcare are increasing, but controversial. The relationship between such online patient reports and conventional measures of patient experience (obtained via survey) is not known. The authors examined hospital level associations between web-based patient ratings on the National Health Service (NHS) Choices website, introduced in England during 2008, and paper-based survey measures of patient experience. The authors also aimed to compare these two methods of measuring patient experience.
The authors performed a cross-sectional observational study of all (n=146) acute general NHS hospital trusts in England using data from 9997 patient web-based ratings posted on the NHS Choices website during 2009/2010. Hospital trust level indicators of patient experience from a paper-based survey (five measures) were compared with web-based patient ratings using Spearman's rank correlation coefficient. The authors compared the strength of associations among clinical outcomes, patient experience survey results and NHS Choices ratings.
Web-based ratings of patient experience were associated with ratings derived from a national paper-based patient survey (Spearman ρ=0.31-0.49, p<0.001 for all). Associations with clinical outcomes were at least as strong for online ratings as for traditional survey measures of patient experience.
Unsolicited web-based patient ratings of their care, though potentially prone to many biases, are correlated with survey measures of patient experience. They may be useful tools for patients when choosing healthcare providers and for clinicians to improve the quality of their services.
BMJ quality & safety 04/2012; 21(7):600-5.
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Archives of internal medicine 02/2012; 172(5):435-6. · 11.46 Impact Factor
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ABSTRACT: Improving communication between caregivers is an important approach to improving safety.
To implement teamwork and communication interventions and evaluate their impact on patient outcomes.
A prospective, interrupted time series of a three-phase
a run-in period (phase 1), during which a training programme was given to providers and staff on each unit; phase 2, which focused on unit-based safety teams to identify and address care problems using skills from phase 1; and phase 3, which focused on engaging patients in communication efforts.
General medical inpatient units at three northern California hospitals.
Administrative data were collected from all adults admitted to the target units, and a convenience sample of patients interviewed during and after hospitalisation.
Readmission, length of stay and patient reports of teamwork, problems with care, and overall satisfaction.
10 977 patients were admitted; 581 patients (5.3% of total sample) were interviewed in hospital, and 313 (2.9% overall, 53.8% of interviewed patients) completed 1-month surveys. No phase of the study was associated with adjusted differences in readmission or length of stay. The phase 2 intervention appeared to be associated with improvement in reports of whether physicians treated them with respect, whether nurses treated them with respect or understood their needs (p<0.05 for all). Interestingly, patients were more likely to perceive that an error took place with their care and agreed less that their caregivers worked well together as a team. No phase had a consistent impact on patient reports of care processes or overall satisfaction. Limitations The study lacks direct measures of patient safety.
Efforts to simultaneously improve caregivers' ability to troubleshoot care and enhance communication may improve patients' perception of team functions, but may also increase patients' perception of safety gaps.
BMJ quality & safety 11/2011; 21(2):118-26.
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ABSTRACT: Healthcare's improvement efforts have focused on the point of care, targeting specific processes such as preventing central line infections, while paying relatively less attention to the larger issues of organizational structure and leadership. Interestingly, the business community has long recognized that poor management and structure can thwart improvement efforts. Perhaps the corporate world's best-known study of these issues is found in the book Good to Great, which identifies top-performing corporations, compares them to carefully selected organizations that failed to achieve similar levels of performance, and gleans lessons from these analyses. In this article, we analyze the feasibility of carefully applying Good to Great's methods for analyzing organizational structure and leadership to healthcare. While a few studies in healthcare have come close to emulating Good to Great's methodology, none have matched its rigor. These shortcomings highlight key information and measurement gaps that must be addressed to facilitate unbiased, rigorous studies of the organizational and leadership predictors of institutional excellence in healthcare. Journal of Hospital Medicine 2011; © 2011 Society of Hospital Medicine.
Journal of Hospital Medicine 10/2011; · 1.40 Impact Factor
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Journal of Hospital Medicine 10/2011; 6(8):457. · 1.40 Impact Factor
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Academic medicine: journal of the Association of American Medical Colleges 10/2011; 86(10):1193-4. · 2.34 Impact Factor
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ABSTRACT: Evaluations of the impact of hospital accreditation have been previously hampered by the lack of nationally standardized data. One way to assess this impact is to compare accreditation status with other evidence-based measures of quality, such as the process measures now publicly reported by The Joint Commission and the Centers for Medicare and Medicaid Services (CMS).
To examine the association between Joint Commission accreditation status and both absolute measures of, and trends in, hospital performance on publicly reported quality measures for common diseases.
Performance data for 2004 and 2008 from U.S. acute care and critical access hospitals were obtained using publicly available CMS Hospital Compare data augmented with Joint Commission performance data.
Changes in hospital performance between 2004 and 2008, and percent of hospitals with 2008 performance exceeding 90% for 16 measures of quality-of-care and 4 summary scores.
Hospitals accredited by The Joint Commission tended to have better baseline performance in 2004 than non-accredited hospitals. Accredited hospitals had larger gains over time, and were significantly more likely to have high performance in 2008 on 13 out of 16 standardized clinical performance measures and all summary scores.
While Joint Commission-accredited hospitals already outperformed non-accredited hospitals on publicly reported quality measures in the early days of public reporting, these differences became significantly more pronounced over 5 years of observation. Future research should examine whether accreditation actually promotes improved performance or is a marker for other hospital characteristics associated with such performance. Journal of Hospital Medicine 2011;6:458-465. © 2011 Society of Hospital Medicine.
Journal of Hospital Medicine 10/2011; 6(8):454-61. · 1.40 Impact Factor
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Archives of internal medicine 07/2011; 171(14):1299-1300. · 11.46 Impact Factor
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ABSTRACT: It is commonly believed that the quality of health care decreases during trainee changeovers at the end of the academic year.
To systematically review studies describing the effects of trainee changeover on patient outcomes.
Electronic literature search of PubMed, Educational Research Information Center (ERIC), EMBASE, and the Cochrane Library for English-language studies published between 1989 and July 2010.
Title and abstract review followed by full-text review to identify studies that assessed the effect of the changeover on patient outcomes and that used a control group or period as a comparator.
Using a standardized form, 2 authors independently abstracted data on outcomes, study setting and design, and statistical methods. Differences between reviewers were reconciled by consensus. Studies were then categorized according to methodological quality, sample size, and outcomes reported.
Of the 39 included studies, 27 (69%) reported mortality, 19 (49%) reported efficiency (length of stay, duration of procedure, hospital charges), 23 (59%) reported morbidity, and 6 (15%) reported medical error outcomes; all studies focused on inpatient settings. Most studies were conducted in the United States. Thirteen (33%) were of higher quality. Studies with higher-quality designs and larger sample sizes more often showed increased mortality and decreased efficiency at time of changeover. Studies examining morbidity and medical error outcomes were of lower quality and produced inconsistent results.
The review was limited to English-language reports. No study focused on the effect of changeovers in ambulatory care settings. The definition of changeover, resident role in patient care, and supervision structure varied considerably among studies. Most studies did not control for time trends or level of supervision or use methods appropriate for hierarchical data.
Mortality increases and efficiency decreases in hospitals because of year-end changeovers, although heterogeneity in the existing literature does not permit firm conclusions about the degree of risk posed, how changeover affects morbidity and rates of medical errors, or whether particular models are more or less problematic.
National Heart, Lung, and Blood Institute.
Annals of internal medicine 07/2011; 155(5):309-15. · 16.73 Impact Factor
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ABSTRACT: Few studies have examined the safety risks of the annual outpatient clinic handoffthat occurs when residents either advance to a higher level of training or graduate ("year-end transfer"). A multifaceted intervention was designed and implemented to identify and improve followup of high-risk patients during academic year-end outpatient transfers in a psychiatry resident continuity clinic.
Departing residents identified "acute" patients, who were scheduled on a priority basis for longer appointments during the first month after the transfer. In addition, standardized written and face-to-face sign-outs occurred, incoming clinicians contacted every patient in the first week, and specialized didactics were provided.
For the three intervention years combined, the odds ratio of hospitalization for acute patients compared to nonacute patients was 9.2 (95% confidence interval [CI]: 2.43, 34.7; p = .001). Compared to Year 1, the proportion of acute patients seen within 31 days in Years 2 and 3 increased by 32.2% (from 64.3% to 85.0%, p < .0001). The median time-to-first visit for acute patients decreased by 42% (from 24 days in Year 1 to 14 days in Year 3, p = .001). Finally, resident perception of the quality of the handoffim-proved in all areas compared to baseline, including resident-to-resident communication (2.8 to 3.0, p = .03), accuracy of caseload lists (2.8 to 4.1,p = .003), identification of high-risk patients (2.1 to 3.7, p < .0001), and usefulness of supervision during the transition (2.7 to 4.3, p < .0001).
Categorical designation by the outgoing clinicians effectively identified patients at higher risk for hospitalization during the transition. Relatively low-cost interventions may significantly improve patient safety and resident training in not only psychiatry, but also other disciplines and specialties.
Joint Commission journal on quality and patient safety / Joint Commission Resources 07/2011; 37(7):300-8.
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Sydney M Dy,
Stephanie L Taylor,
Lauren H Carr,
Robbie Foy,
Peter J Pronovost,
John Ovretveit, Robert M Wachter,
Lisa V Rubenstein,
Susanne Hempel,
Kathryn M McDonald,
Paul G Shekelle
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ABSTRACT: Development of a coherent literature evaluating patient safety practices has been hampered by the lack of an underlying conceptual framework. The authors describe issues and choices in describing and classifying diverse patient safety practices (PSPs).
The authors developed a framework to classify PSPs by identifying and synthesising existing conceptual frameworks, evaluating the draft framework by asking a group of experts to use it to classify a diverse set of PSPs and revising the framework through an expert-panel consensus process.
The 11 classification dimensions in the framework include: regulatory versus voluntary; setting; feasibility; individual activity versus organisational change; temporal (one-time vs repeated/long-term); pervasive versus targeted; common versus rare events; PSP maturity; degree of controversy/conflicting evidence; degree of behavioural change required for implementation; and sensitivity to context.
This framework offers a way to classify and compare PSPs, and thereby to interpret the patient-safety literature. Further research is needed to develop understanding of these dimensions, how they evolve as the patient safety field matures, and their relative utilities in describing, evaluating and implementing PSPs.
BMJ quality & safety 07/2011; 20(7):618-24.
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ABSTRACT: Differences in contexts (eg, policies, healthcare organisation characteristics) may explain variations in the effects of patient safety practice (PSP) implementations. However, knowledge of which contextual features are important determinants of PSP effectiveness is limited and consensus is lacking on a taxonomy of which contexts matter.
Iterative, formal discussions were held with a 22-member technical expert panel composed of experts or leaders in patient safety, healthcare systems, and methods. First, potentially important contextual features were identified, focusing on five PSPs. Then, two surveys were conducted to determine the context likely to influence PSP implementations.
The panel reached a consensus on a taxonomy of four broad domains of contextual features important for PSP implementations: safety culture, teamwork and leadership involvement; structural organisational characteristics (eg, size, organisational complexity or financial status); external factors (eg, financial or performance incentives or PSP regulations); and availability of implementation and management tools (eg, training organisational incentives). Panelists also tended to rate specific patient safety culture, teamwork and leadership contexts as high priority for assessing their effects on PSP implementations, but tended to rate specific organisational characteristic contexts as high priority only for use in PSP evaluations. Panelists appeared split on whether specific external factors and implementation/management tools were important for assessment or only description.
This work can guide research commissioners and evaluators on the contextual features of PSP implementations that are important to report or evaluate. It represents a first step towards developing guidelines on contexts in PSP implementation evaluations. However, the science of context measurement needs maturing.
BMJ quality & safety 07/2011; 20(7):611-7.
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ABSTRACT: BACKGROUND: Despite widespread emphasis on promoting 'assertive communication' by care givers as essential to patient-safety-improvement efforts, little is known about when and how clinicians speak up to address safety concerns. In this cross-sectional study, the authors use a new measure of speaking up to begin exploring this issue in maternity care. METHODS: The authors developed a scenario-based measure of clinician's assessment of potential harm and likelihood of speaking up in response to perceived harm. The authors embedded this scale in a survey with measures of safety climate, teamwork climate, disruptive behaviour, work stress, and personality traits of bravery and assertiveness. The survey was distributed to all registered nurses and obstetricians practising in two US Labour & Delivery units. RESULTS: The response rate was 54% (125 of 230 potential respondents). Respondents were experienced clinicians (13.7±11 years in specialty). A higher perception of harm, respondent role, specialty experience and site predicted the likelihood of speaking up when controlling for bravery and assertiveness. Physicians rated potential harm in common clinical scenarios lower than nurses did (7.5 vs 8.4 on 2-10 scale; p<0.001). Some participants (12%) indicated they were unlikely to speak up, despite perceiving a high potential for harm in certain situations. DISCUSSION: This exploratory study found that nurses and physicians differed in their harm ratings, and harm rating was a predictor of speaking up. This may partially explain persistent discrepancies between physicians and nurses in teamwork climate scores. Differing assessments of potential harms inherent in everyday practice may be a target for teamwork intervention in maternity care.
BMJ quality & safety 07/2011;
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ABSTRACT: Logic and experience suggest that it is easier in some situations than in others to change behaviour and organisation to improve patient safety. Knowing which 'context factors' help and hinder implementation of different changes would help implementers, as well as managers, policy makers, regulators and purchasers of healthcare. It could help to judge the likely success of possible improvements, given the conditions that they have, and to decide which of these conditions could be modified to make implementation more effective.
The study presented in this paper examined research to discover any evidence reported about whether or how context factors influence the effectiveness of five patient safety interventions.
The review found that, for these five diverse interventions, there was little strong evidence of the influence of different context factors. However, the research was not designed to investigate context influence.
The paper suggests that significant gaps in research exist and makes proposals for future research better to inform decision-making.
BMJ quality & safety 07/2011; 20(7):604-10.
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Paul G Shekelle,
Peter J Pronovost, Robert M Wachter,
Stephanie L Taylor,
Sydney M Dy,
Robbie Foy,
Susanne Hempel,
Kathryn M McDonald,
John Ovretveit,
Lisa V Rubenstein, [......],
Kathleen N Lohr,
Gregg S Meyer,
Marlene R Miller,
Duncan V Neuhauser,
Gery Ryan,
Sanjay Saint,
Kaveh G Shojania,
Stephen M Shortell,
David P Stevens,
Kieran Walshe
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ABSTRACT: Despite a decade's worth of effort, patient safety has improved slowly, in part because of the limited evidence base for the development and widespread dissemination of successful patient safety practices. The Agency for Healthcare Research and Quality sponsored an international group of experts in patient safety and evaluation methods to develop criteria to improve the design, evaluation, and reporting of practice research in patient safety. This article reports the findings and recommendations of this group, which include greater use of theory and logic models, more detailed descriptions of interventions and their implementation, enhanced explanation of desired and unintended outcomes, and better description and measurement of context and of how context influences interventions. Using these criteria and measuring and reporting contexts will improve the science of patient safety.
Annals of internal medicine 05/2011; 154(10):693-6. · 16.73 Impact Factor
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ABSTRACT: Effective communication is a hallmark of safe patient care. Challenges to effective interprofessional communication in maternity care include differing professional perspectives on clinical management, steep hierarchies, and lack of administrative support for change. We review principles of high reliability as they apply to communication in clinical care and discuss principles of effective communication and conflict management in maternity care. Effective clinical communication is respectful, clear, direct, and explicit. We use a clinical scenario to illustrate an historic style of nurse-physician communication and demonstrate how communication can be improved to promote trust and patient safety. Consistent execution of successful communication requires excellent listening skills, superb administrative support, and collective commitment to move past traditional hierarchy and professional stereotyping.
American journal of obstetrics and gynecology 04/2011; 205(2):91-6. · 3.28 Impact Factor
