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A realist analysis of hospital patient safety in Wales: applied learning for alternative contexts from a multisite case study
Abstract
Hospital patient safety is a major social problem. In the UK, policy responses focus on the introduction of improvement programmes that seek to implement evidence-based clinical practices using the Model for Improvement, Plan-Do-Study-Act cycle. Empirical evidence that the outcomes of such programmes vary across hospitals demonstrates that the context of their implementation matters. However, the relationships between features of context and the implementation of safety programmes are both undertheorised and poorly understood in empirical terms.
Objectives
This study is designed to address gaps in conceptual, methodological and empirical knowledge about the influence of context on the local implementation of patient safety programmes.
Design
We used concepts from critical realism and institutional analysis to conduct a qualitative comparative-intensive case study involving 21 hospitals across all seven Welsh health boards. We focused on the local implementation of three focal interventions from the 1000 Lives
+
patient safety programme: Improving Leadership for Quality Improvement, Reducing Surgical Complications and Reducing Health-care Associated Infection. Our main sources of data were 160 semistructured interviews, observation and 1700 health policy and organisational documents. These data were analysed using the realist approaches of abstraction, abduction and retroduction.
Setting
Welsh Government and NHS Wales.
Participants
Interviews were conducted with 160 participants including government policy leads, health managers and professionals, partner agencies with strategic oversight of patient safety, advocacy groups and academics with expertise in patient safety.
Main outcome measures
Identification of the contextual factors pertinent to the local implementation of the 1000 Lives
+
patient safety programme in Welsh NHS hospitals.
Results
An innovative conceptual framework harnessing realist social theory and institutional theory was produced to address challenges identified within previous applications of realist inquiry in patient safety research. This involved the development and use of an explanatory intervention–context–mechanism–agency–outcome (I-CMAO) configuration to illustrate the processes behind implementation of a change programme. Our findings, illustrated by multiple nested I-CMAO configurations, show how local implementation of patient safety interventions are impacted and modified by particular aspects of context: specifically, isomorphism, by which an intervention becomes adapted to the environment in which it is implemented; institutional logics, the beliefs and values underpinning the intervention and its source, and their perceived legitimacy among different groups of health-care professionals; and the relational structure and power dynamics of the functional group, that is, those tasked with implementing the initiative. This dynamic interplay shapes and guides actions leading to the normalisation or the rejection of the patient safety programme.
Conclusions
Heightened awareness of the influence of context on the local implementation of patient safety programmes is required to inform the design of such interventions and to ensure their effective implementation and operationalisation in the day-to-day practice of health-care teams. Future work is required to elaborate our conceptual model and findings in similar settings where different interventions are introduced, and in different settings where similar innovations are implemented.
Funding
The National Institute for Health Research Health Services and Delivery Research programme.
... As a middle range theory, NPT has been increasingly applied to many different healthcare specialities and contexts, including mental health [13], allied health [14], acute healthcare [15], primary healthcare settings [16,17] and medical revalidation [18] as an explanatory model to guide the development and implementation of complex interventions. We chose the NPT as an explanatory model to explore and evaluate the implementation of a complex intervention in the Operating Room (OR) context. ...
... Core constructs, Generative mechanisms of NPT and illustrative questions mapped against categories and codes identified through 8 qualitative interviews (n = 26) Core Constructs and Generative Mechanisms of NPT (May et al.[15]) ...
Background:
The surgical Safety Checklist (SSC) was introduced in 2008 to improve teamwork and reduce the mortality and morbidity associated with surgery. Although mandated in many health care institutions around the world, challenges in implementation of the SSC continue. To use Normalisation Process Theory (NPT) to help understand how/why implementation of a complex intervention coined Pass The Baton (PTB) could help explain what facets of the Surgical Safety Checklist use led to its' integration in practice, while others were not.
Methods:
A longitudinal multi-method study using survey and interviews was undertaken. Implementation of PTB involved; change champions, audit and feedback, education and prompts. Following implementation, surgical teams were surveyed using the NOrmalization MeAsure Development (NoMAD) and subsequently interviewed to explore the impact of PTB on their use of the checklist at 6 and 12 months respectively. Respondents' self-reported perceptions of implementation of PTB was explained using the four NPT constructs; coherence, cognitive participation, collective action, and reflexive monitoring. Survey data were analysed using descriptive statistics. Interview data were coded inductively and content analysed using a framework derived from NPT.
Results:
The NoMAD survey response rate was 59/150 (39.3%). Many (45/59, 77.6%) survey respondents saw the value in PTB, while 50/59 (86.2%) would continue to use it; 45/59 (77.6%) believed that PTB could easily be integrated into existing workflows, and 48/59 (82.8%) thought that feedback could improve PTB in the future. A total of 8 interviews were completed with 26 surgical team members. Nurses and physicians held mixed views towards coherence while buy-in and participation relied on individuals' investment in the implementation process and the ability to modify PTB. Participants generally recognised the benefit and value of using PTB in the ongoing implementation the checklist.
Conclusions:
Workarounds and flexible co-construction in implementation designed to improve team communications in surgery may facilitate their normalisation in practice.
... Kajian kes meneroka dan menganalisis secara terperinci kes tertentu. Dalam konteks pengurusan risiko keselamatan, pendekatan ini memberikan pandangan tentang insiden sebenar, menggambarkan amalan keselamatan, cabaran dan kesannya (Herepath, Kitchener & Waring 2015). Penyelidikan gunaan menyumbang 13.04% daripada kajian, dengan tiga dalam kategori ini. ...
Pengurusan risiko keselamatan merupakan aspek kritikal dalam makmal kejuruteraan disebabkan oleh uji kaji yang kompleks dan kemunculan teknologi terkini yang meningkatkan risiko kemungkinan berlakunya kemalangan. Kajian kepustakaan sistematik ini melibatkan 23 artikel yang mematuhi garis panduan PRISMA dan mengkategorikan faktor yang mempengaruhi protokol keselamatan. Kajian ini memfokuskan kepada persoalan kajian iaitu apakah faktor utama yang mempengaruhi amalan pengurusan risiko keselamatan di makmal kejuruteraan dan bagaimanakah faktor ini mempengaruhi persekitaran keselamatan di makmal? Melalui penyelidikan ini, faktor penyumbang telah dikenal pasti dan dikelaskan ke dalam lima tema utama: 1) Protokol Pengurusan Risiko, 2) Faktor Organisasi, 3) Faktor Fizikal dan Persekitaran, 4) Faktor Luar dan Kontekstual dan 5) Hala Tuju Inovatif Baharu. Bidang ini mempengaruhi tindakan keselamatan dengan cara yang kompleks. Hasil kajian ini memaparkan protokol keselamatan yang berkesan, integriti organisasi, pematuhan peraturan dan strategi keselamatan yang inovatif. Pemahaman yang lebih mendalam ini meningkatkan langkah keselamatan, mengurangkan kemalangan, memacu budaya mengutamakan keselamatan dan menjamin pematuhan keselamatan. Kajian ini secara signifikan menyumbang kepada pengetahuan saintifik tentang pengurusan risiko keselamatan di makmal kejuruteraan, menangani keperluan kritikal untuk melindungi kesejahteraan manusia dan alam sekitar.
... The work was conducted utilising a realist lens, whereby we sought to better bridge the gap between research, policy, and practice by acknowledging that there was an external reality (i.e., a real world that exists independent of the research work) and that this reality could be understood by collecting objective, unbiased data about that reality [18]. Simply put, we believed that these new sub-models already existed in some form, either in a pure sense or as hybrid models. ...
Background:
Over the past 60 years since its inception, the Anglo-American Paramedic System has continued to grow and evolve. While brief and fragmented accounts of the differences between systems have been noted in the literature, until recently there has been a paucity of research that explores and identifies sub-models of paramedicine within the Anglo-American Paramedic System.
Objectives:
This article describes a conceptual framework that sets a roadmap for defining and comparing two newly identified sub-models of the Anglo-American Paramedic System.
Methods:
A conceptual framework for the exploration of these novel sub-models was developed on the basis of the work completed by Donabedian as well as Turncock and Handler. These two sub-models worked to develop a model for quality assessment and performance measurement in the public health system.
Results:
The conceptual framework consists of six components that are strongly related to each other: system design, macro context, mission and purpose, structure, service delivery models and quality outcome measures. While this framework relates specifically to two novel paramedic systems known as the Professionally Autonomous an Directive paramedic systems, it can be used to measure any integrated health model.
Conclusion:
The conceptual framework described in this paper provides a stepwise roadmap for the definition and comparison of the newly identified paramedic systems to better inform future research that defines and compares paramedic system design and performance.
... Several models are available for articulating theory configurations. 36,37 We found that separating the learner context from the educational strategy helped us to isolate the mechanisms leading to changes in perspective. We therefore chose to use the context-intervention-mechanism-outcome configuration (CIMOc) for our realist causal explanations. ...
Context
Person-centeredness is a stated aim for medical education; however, studies suggest this is not being achieved. There is a gap in our understanding of how, why and in what circumstances medical education interventions that aim to develop person-centredness are successful.
Methods
A realist review was conducted with a search of Medline, Embase, HMIC, and ERIC databases and the grey literature using the terms “medical education” and “person-centred” and related synonyms. Studies which involved a planned educational intervention in medical education with data on outcomes related to person-centredness were included. The analysis focussed on how and why different educational strategies interact with biomedical learner perspectives to trigger mechanisms that may or may not lead to a change in perspective towards person-centredness.
Results
Sixty-one papers representing fifty-three interventions were included in the final synthesis. Nine context-intervention-mechanism-outcome (CIMOc) statements generated from the data synthesis make up our refined programme theory. Where educational interventions focussed on communication skills learning or experiences without person-centred theory, learners experienced dissonance with their biomedical perspective which they resolved by minimising the importance of the learning, resulting in perspective endurance. Where educational interventions applied person-centred theory to meaningful experiences and included support for sense-making, learners understood the relevance of person-centeredness and felt able to process their responses to learning, resulting in perspective transformation towards person-centredness.
Conclusion
Our findings offer explanations as to why communication skills-based interventions, may be insufficient to develop learners’ person-centredness. Integrating experiential person-centred learning with theory on why person-centredness matters to clinical practice and enabling learners to make sense of their responses to learning, may support perspective transformation towards person-centredness. Our findings offer programme and policy makers testable theory to inform the development of medical education strategies that aim to support person-centredness.
... 41 Data will be collated from numerous sources to posit, test and refine hypothesised theories for how implementation strategies and processes lead to intended or unintended outcomes, depending on the influence of various contextual factors (eg, structure, relations, culture). [42][43][44][45] We will use both qualitative and quantitative data to uncover these patterns of outcomes in different contexts and to explicate the mechanisms for implementing value-based healthcare initiatives. Our iterative, three-stage model is depicted in figure 2 (Source: Adapted from Pawson et al, 34 Panmunthygala et al, 46 CMO: context-mechanism-outcome). ...
Introduction
Value-based healthcare delivery models have emerged to address the unprecedented pressure on long-term health system performance and sustainability and to respond to the changing needs and expectations of patients. Implementing and scaling the benefits from these care delivery models to achieve large-system transformation are challenging and require consideration of complexity and context. Realist studies enable researchers to explore factors beyond ‘what works’ towards more nuanced understanding of ‘what tends to work for whom under which circumstances’. This research proposes a realist study of the implementation approach for seven large-system, value-based healthcare initiatives in New South Wales, Australia, to elucidate how different implementation strategies and processes stimulate the uptake, adoption, fidelity and adherence of initiatives to achieve sustainable impacts across a variety of contexts.
Methods and analysis
This exploratory, sequential, mixed methods realist study followed RAMESES II (Realist And Meta-narrative Evidence Syntheses: Evolving Standards) reporting standards for realist studies. Stage 1 will formulate initial programme theories from review of existing literature, analysis of programme documents and qualitative interviews with programme designers, implementation support staff and evaluators. Stage 2 envisages testing and refining these hypothesised programme theories through qualitative interviews with local hospital network staff running initiatives, and analyses of quantitative data from the programme evaluation, hospital administrative systems and an implementation outcome survey. Stage 3 proposes to produce generalisable middle-range theories by synthesising data from context–mechanism–outcome configurations across initiatives. Qualitative data will be analysed retroductively and quantitative data will be analysed to identify relationships between the implementation strategies and processes, and implementation and programme outcomes. Mixed methods triangulation will be performed.
Ethics and dissemination
Ethical approval has been granted by Macquarie University (Project ID 23816) and Hunter New England (Project ID 2020/ETH02186) Human Research Ethics Committees. The findings will be published in peer-reviewed journals. Results will be fed back to partner organisations and roundtable discussions with other health jurisdictions will be held, to share learnings.
... In many industries organizations use management systems to help them to achieve their objectives. In healthcare, management systems enable organizations to organize the quality and safety of care systematically (Herepath, Kitchener, & Waring, 2015). The main operating mechanism of management systems is typically based on a cyclic process of plan, do, check and act. ...
The concept of decoupling refers to the gap between the formal and the actual world in organizations in which a policy is formally introduced but not actually implemented and effective. Although the phenomenon of decoupling in organizations has been studied widely since the late 1970s, little is known about the reverse process of recoupling. Little is also known about the abilities of public regulators to discover decoupling in regulated organizations and to promote the recoupling that is necessary to diminish the gap between the formal and the actual world.
In an experimental project of the Dutch Healthcare Inspectorate, we ethnographically followed how this public regulator changes the focus from prescriptive regulation based on quality and safety indicators to the supervision of the management system of a regulated organization. We call this type of regulation system-based regulation (SBR).
We found that, by using SBR, a regulator can identify several forms of decoupling that have not been recognized in earlier research. Interestingly, we found indications that, by applying SBR and thus recognizing decoupling, a process of recoupling was supported. With SBR the government can reclaim its influence on the meta level whilst maintaining the level of freedom of management at the organizational level. Instead of aiming for more or stricter regulation, the government could shift its role to meta regulation, meaning that the public regulator redefines its role as an assessor and stimulator of the quality of governance in terms of self-regulation. Implications for theory and practice are discussed.
... Other accounts have referenced the use of a framework of substantive theories which informed the initial stages of theory development (Herepath, Kitchener, & Waring, 2015;Westhorp, 2013). What we have added here is a detailed account of how this framework can be used, in conjunction with initial data, to inspire the development of initial theory propositions. ...
Program theory, that is, the specific idea about how a program causes the intended or observed outcomes, should be the central aspect of any realist evaluation or synthesis. The methods used for explicating or building initial rough program theories (IRPTs) in realist research are varied and arguably often underreported. In addition, preexisting psychological and sociological theories, at a higher level of abstraction, could be used to a greater extent to inform their development. This article illustrates a method for building IRPTs for use in realist research evaluation and synthesis. This illustration involves showing how the IRPTs were developed in a realist evaluation concerning sexual health services for young people. In this evaluation, a broad framework of abstract theories was constructed early in the process to support IRPT building and frame more specific program theories as they were developed. These abstract theories were selected to support theorizing at macro-, meso-, and microlevels of social structure. This article discusses the benefits of using this method to build initial theories for particular types of interventions that are large, complex, and messy. It also addresses challenges relating to the selection of suitable theories.
Background
In health care, errors could have serious consequences for patients and staff. High-risk industries, such as aviation, have improved safety by taking a systems approach, known as safety management systems. Safety management systems are generally considered to have four key components: leadership commitment and safety policy; safety risk management; safety assurance; and safety culture. Safety management systems need to be context-specific to be effective. Evidence on the use of safety management systems in health care is therefore needed to inform policy decisions.
Objectives
To investigate the application of safety management systems to patient safety in terms of effectiveness, implementation and experience.
Methods
We conducted a systematic review of research and other evidence from high-income countries that have publicly funded healthcare systems with universal coverage and key evidence available in English. We included Australia, Canada, Ireland, New Zealand and the Netherlands.
We searched the websites of, and contacted experts from, patient safety organisations in each country, and searched MEDLINE (December 2023) and EMBASE (via Ovid), Cumulative Index to Nursing and Allied Health Literature (EBSCO) and Web of Science (February 2024). We included policy documents, research and other evidence relating to the effectiveness, implementation or experience of the safety approach in each country.
We summarised and mapped included evidence onto an initial framework based on analysis of safety management systems in high-risk industries. We shared drafts with experts in each country for comment. No standardised quality appraisal was conducted but those studies evaluating impact were critically examined for risk of bias.
Results
Fifty-three publications were included, from Australia (5), Canada (7), Ireland (8), New Zealand (9) and the Netherlands (24).
The Netherlands was the only country with a patient safety programme explicitly based on a safety management system approach. The programme was associated with improvement in some aspects of patient safety in hospitals but there was significant variation in its implementation and outcomes.
The main components of a safety management system were also identified to some extent in the patient safety approaches of the other four countries, along with evidence of influence from high-risk industries and ‘safety science’ more widely.
Limitations
Although we followed best practice for conducting systematic reviews, some limitations should be acknowledged. We did not conduct formal quality appraisal, but the risk of bias in studies evaluating impact was examined. We also tried to mitigate the risk of partial understanding (from the use of policy documents) by talking to experts from each country.
Conclusions
Only the Dutch patient safety programme was explicitly based on a safety management system approach. Concepts from high-risk industries and broader safety science had influenced the patient safety approach in the other countries, and the ongoing approach in the Netherlands, but this was less systematic and explicit. Approaches to patient safety in all countries reflect increasing awareness that for an initiative to be successful, it needs to be context-specific.
Future work
Using realist methods to identify mechanisms underpinning the success of different patient safety approaches could allow better understanding of how and to what extent such initiatives work in specific circumstances. Methods for evaluation of impact also require further development to allow better understanding and comparison of different approaches.
Study registration
This study is registered as PROSPERO CRD42023487512.
Funding
This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR136105) and is published in full in Health and Social Care Delivery Research ; Vol. 13, No. 7. See the NIHR Funding and Awards website for further award information.
Background
As a matter of policy, voluntary, community and social enterprises contribute substantially to the English health and care system. Few studies explain how the National Health Service and local authorities commission them, what outputs result, what contexts influence these outcomes and what differentiates this kind of commissioning.
Objectives
To explain how voluntary, community and social enterprises are commissioned, the consequences, what barriers both parties face and what absorptive capacities they need.
Design
Observational mixed-methods realist analysis: exploratory scoping, cross-sectional analysis of National Health Service Clinical Commissioning Group spending on voluntary, community and social enterprises, systematic comparison of case studies, action learning. Social prescribing, learning disability support and end-of-life care were tracers.
Setting
Maximum-variety sample of six English local health and care economies, 2019–23.
Participants
Commissioning staff; voluntary, community and social enterprise members.
Interventions
None; observational study.
Main outcome measures
How the consequences of commissioning compared with the original aims of the commissioners and the voluntary, community and social enterprises: predominantly qualitative (non-measurable) outcomes.
Data sources
Data sources were: 189 interviews, 58 policy and position papers, 37 items of rapportage, 692,659 Clinical Commissioning Group invoices, 102 Freedom of Information enquiries, 131 survey responses, 18 local project group meetings, 4 national action learning set meetings. Data collected in England during 2019–23.
Results
Two modes of commissioning operated in parallel. Commodified commissioning relied on creating a principal–agent relationship between commissioner and the voluntary, community and social enterprises, on formal competitive selection (‘procurement’) of providers. Collaborative commissioning relied on ‘embedded’ interorganisational relationships, mutual recognition of resource dependencies, a negotiated division of labour between organisations, and control through persuasion. Commissioners and voluntary, community and social enterprises often worked around the procurement regulations. Both modes were present everywhere but the balance depended inter alia on the number and size of voluntary, community and social enterprises in each locality, their past commissioning experience, the character of the tracer activity, and the level of deprivation and the geographic dispersal of the populations served. The COVID-19 pandemic produced a shift towards collaborative commissioning. Voluntary, community and social enterprises were not always funded at the full cost of their activity. Integrated Care System formation temporarily disrupted local co-commissioning networks but offered a longer-term prospect of greater voluntary, community and social enterprise influence on co-commissioning. To develop absorptive capacity, commissioners needed stronger managerial and communication capabilities, and voluntary, community and social enterprises needed greater capability to evidence what outcomes their proposals would deliver.
Limitations
Published data quality limited the spending profile accuracy, which did not include local authority commissioning. Case studies did not cover London, and focused on three tracer activities. Absorptive capacity survey was not a random sample.
Conclusions
The two modes of commissioning sometimes conflicted. Workarounds arose from organisations’ embeddedness and collaboration, which the procurement regulations often disrupted. Commissioning activity at below its full cost appears unsustainable.
Future work
Spending profiles of local authority commissioning; analysis of commissioning in London and of activities besides the present tracers. Analysis of absorptive capacity and its consequences, adjusting the concept for application to voluntary, community and social enterprises. Comparison with other health systems’ commissioning of voluntary, community and social enterprises.
Funding
This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR128107) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 39. See the NIHR Funding and Awards website for further award information.
the impact of patient safety application and healthcare quality improvement
Background
Previous studies have detailed the technical, learning and soft skills healthcare staff deploy to deliver quality improvement (QI). However, research has mainly focused on management and leadership skills, overlooking the skills frontline staff use to improve care. Our research explored which skills mattered to frontline health practitioners delivering QI projects.
Study design
We used a theory-driven approach, informed by communities of practice, knowledge-in-practice-in-context and positive deviance theory. We used case studies to examine skill use in three pseudonymised English hospital Trusts, selected on the basis of Care Quality Commission rating. Seventy-three senior staff orientation interviews led to the selection of two QI projects at each site. Snowball sampling obtained a maximally varied range of 87 staff with whom we held 122 semistructured interviews at different stages of QI delivery, analysed thematically.
Results
Six overarching ‘Socio-Organisational Functional and Facilitative Tasks’ (SOFFTs) were deployed by frontline staff. Several of these had to be enacted to address challenges faced. The SOFFTs included: (1) adopting and promulgating the appropriate organisational environment; (2) managing the QI rollercoaster; (3) getting the problem right; (4) getting the right message to the right people; (5) enabling learning to occur; and (6) contextualising experience. Each task had its own inherent skills.
Conclusion
Our case studies provide a nuanced understanding of the skills used by healthcare staff. While technical skills are important, the ability to judge when and how to use wider skills was paramount. The provision of QI training and fidelity to the improvement programme may be less of a priority than the deployment of SOFFT skills used to overcome barriers. QI projects will fail if such skills and resources are not accessed.
Realist evaluation has become widespread partly because of its sensitivity to the influence of contexts on policy implementation. In many such evaluations, the range of contexts considered relevant nevertheless remains disparate and under-conceptualised. This article uses findings from a realist evaluation of English Patient Safety Collaboratives during 2015–2018 to develop a realist taxonomy of contexts, differentiating contexts according to how they affect the corresponding policy mechanism. By analysing the main context-mechanism-outcome configurations that made up the English Patient Safety Collaboratives, we derive a taxonomy of the contexts that affected implementation and outcomes. The categories of context were structural (network, hierarchy, market and organisational contexts); resource-based (actors, material, financial); motivational (receptivity, outcome headroom), and temporal (continuity, history and convergence). To the categories found in previous studies, this study adds the three temporal contexts.
This study aims to describe implementation of simulator-based medical team training and the effect of this programme on inter-professional working in an intensive care unit (ICU).
Over a period of two years, 90 percent (n = 152) of the staff of the general ICU at Karolinska University Hospital, Huddinge, Sweden, received inter-professional team training in a fully equipped patient room in their own workplace. A case study method was used to describe and explain the planning, formation, and results of the training programme.
In interviews, the participants reported that the training had increased their awareness of the importance of effective communication for patient safety. The intervention had even had an indirect impact by creating a need to talk, not only about how to communicate efficaciously, but also concerning difficult care situations in general. This, in turn, had led to regular reflection meetings for nurses held three times a week. Examples of better communication in acute situations were also reported. However, the findings indicate that the observed improvements will not last, unless organisational features such as staffing rotas and scheduling of rounds and meetings can be changed to enable use of the learned behaviours in everyday work. Other threats to sustainability include shortage of staff, overtime for staff, demands for hospital beds, budget cuts, and poor staff communication due to separate meetings for nurses and physicians.
The present results broaden our understanding of how to create and sustain an organizational system that supports medical team training.
Falls are common among inpatients. Several reviews, including 4 meta-analyses involving 19 studies, show that multicomponent programs to prevent falls among inpatients reduce relative risk for falls by as much as 30%. The purpose of this updated review is to reassess the benefits and harms of fall prevention programs in acute care settings and to identify factors associated with successful implementation of these programs. We searched for new evidence using PubMed from 2005 to September 2012. Two new, large, randomized, controlled trials supported the conclusions of the existing meta-analyses. An optimal bundle of components was not identified. Harms were not systematically examined, but potential harms included increased use of restraints and sedating drugs and decreased efforts to mobilize patients. Eleven studies showed that the following themes were associated with successful implementation: leadership support, engagement of front-line staff in program design, guidance of the prevention program by a multidisciplinary committee, pilot-testing interventions, use of information technology systems to provide data about falls, staff education and training, and changes in nihilistic attitudes about fall prevention. Future research would advance knowledge by identifying optimal bundles of component interventions for particular patients and by determining whether effectiveness relies more on the mix of the components or use of certain implementation strategies. Ann Intern Med. 2013;158:390-396. www.annals.org
We develop a contingency theory for how structural closure in a network, defined as terms of the extent to which an actor's network contacts are connected to one another, affects the initiation and adoption of change in organizations. Using longitudinal survey data supplemented with eight in-depth case studies, we analyze 68 organizational change initiatives undertaken in the United Kingdom's National Health Service. We show that low levels of structural closure (i.e., "structural holes") in a change agent's network aid the initiation and adoption of changes that diverge from the institutional status quo but hinder the adoption of less divergent changes.
GPs are the champions of patient safety for their patients and have future possibility for driving patient safety across the entire health services. To fulfil this challenge clinicians need to consider how the techniques and tools widely applied in hospital care might best be used within primary care. This includes developing robust systems to effectively identify and capture information about safety events, procedures and collaborative activities to investigate and analyse safety event, and incentives and penalties for implementing safety improvements.
Patient safety should be at the forefront of health-care. Primary care clinicians have the opportunity to drive this agenda in the future.
Objectives:
To evaluate the development of pharmacist-led antimicrobial stewardship activities in English hospitals.
Methods:
Distribution of an electronic questionnaire to antimicrobial pharmacists or chief pharmacists in National Health Service hospitals in England.
Results:
Since a previous study, in 2005, overall numbers of specialist antimicrobial pharmacists, and their levels of experience, had increased. Over 95% of hospitals provided empirical usage guidance, antimicrobial formularies and surgical prophylaxis guidelines. Two-thirds of pharmacy departments provided antimicrobial usage reports in terms of defined daily doses at least yearly, and over 80% conducted yearly antimicrobial point prevalence studies. The vast majority of pharmacy departments indicated a willingness to supply data and audit results to a national database for benchmarking purposes.
Conclusions:
The increasing role of specialist pharmacists and general pharmacists in antibiotic stewardship in acute care in England has enabled hospitals to deliver on the antibiotic stewardship agenda, although opportunity remains to expand this role further and ensure greater multidisciplinary engagement.
Building on her seminal contribution to social theory in Culture and Agency, in this 1995 book Margaret Archer develops her morphogenetic approach, applying it to the problem of structure and agency. Since structure and agency constitute different levels of stratified social reality, each possesses distinctive emergent properties which are real and causally efficacious but irreducible to one another. The problem, therefore, is shown to be how to link the two rather than conflate them, as has been common theoretical practice. Realist Social Theory: The Morphogenetic Approach not only rejects methodological individualism and holism, but argues that the debate between them has been replaced by a new one, between elisionary theorising and emergentist theories based on a realist ontology of the social world. The morphogenetic approach is the sociological complement of transcendental realism, and together they provide a basis for non-conflationary theorizing which is also of direct utility to the practising social analyst.
Humanity and the very notion of the human subject are under threat from postmodernist thinking which has declared not only the 'Death of God' but also the 'Death of Man'. This book is a revindication of the concept of humanity, rejecting contemporary social theory that seeks to diminish human properties and powers. Archer argues that being human depends on an interaction with the real world in which practice takes primacy over language in the emergence of human self-consciousness, thought, emotionality and personal identity - all of which are prior to, and more basic than, our acquisition of a social identity. This original and provocative new book from leading social theorist Margaret S. Archer builds on the themes explored in her previous books Culture and Agency (CUP 1988) and Realist Social Theory (CUP 1995). It will be required reading for academics and students of social theory, cultural theory, political theory, philosophy and theology.
BACKGROUND:
Gram-negative bacilli, including multi-drug-resistant (MDR) Pseudomonas aeruginosa, are responsible for severe intensive care unit (ICU)-acquired infections, mainly pneumonia and bacteremia. The aim of this study was to determine the incidence of MDR strains of Pseudomonas in patients undergoing cardiac surgery, to elucidate the effectiveness of treating these patients with colistin, and to assess the safety of the drug.
METHODS:
A prospective study was conducted among 1,452 patients who underwent surgery for a variety of cardiac lesions over a one-year period, and who spent a portion of the recovery period in the surgical ICU. Their case histories were analyzed to identify infectious complications. Diagnosis of infection was based on clinical data, and the pathogen was tested with respect to its susceptibility to colistin (polymyxin E). The clinical response to the antibiotic was evaluated.
RESULTS:
Over the 12-month period, among 115 infected patients, 15 were affected by strains of P. aeruginosa. In 10 patients, this pathogen proved resistant to all potentially active antibiotics except colistin. All of the affected patients were being ventilated mechanically, and eight of them presented with ventilator-associated pneumonia (VAP), whereas one patient suffered a deep incisional surgical site infection and bacteremia and the remaining patient had a superficial infection of a lower-extremity vein graft donor site. The MDR pathogen was introduced to the hospital by three patients transferred from three institutions. All patients were treated with intravenous colistin. In cases of VAP, aerosolized colistin was added. Deterioration of renal function occurred in three patients (30%), all of whom had a history of renal insufficiency. Cure or clinical improvement was observed in seven patients (70%), whereas four patients, including one who improved initially, developed sepsis and died with multiple organ dysfunction syndrome (mortality rate 40%).
CONCLUSIONS:
The increasing prevalence of MDR P. aeruginosa in ICU patients has rekindled interest in polymyxins, which had been abandoned because of toxic side effects. Colistin retained significant in vitro activity against this virulent organism, had an acceptable safety profile, and should be considered as a treatment option in critically ill patients with infection caused by MDR gram-negative bacilli. Aerosolized colistin may merit further consideration as a therapeutic intervention for patients with refractory pulmonary infections.
This paper examines how contradictory logics co-exist over time. We study the case of a privatized company experiencing a salient contradiction between regulatory and market logics while implementing a new regulatory policy. We find that work practices and institutional accounts of these practices evolve over three phases: (1) compartmentalized work practices that trade off opposing logics, (2) confrontational work practices that polarize opposition between logics, and (3) mutual adjustment in work practices that enables interdependent accounts of logics. The phases progressively reconfigure the coexistence of institutional logics within the organization, enabling actors to attain partial reconciliation. These findings contribute to understanding how the configuration of contradictory organizational logics changes over time through shifts in practice and legitimating accounts.
Despite little evidence of effectiveness, pay-for-performance programs are being adopted with the intent of improving the quality of care. The few studies evaluating these programs have shown only modest and short-term effects on hospital processes of care and even weaker evidence for effects on patient outcomes. In 2008, the Advancing Quality program was introduced in all 24 National Health Service hospitals in the northwest region of England that provided emergency care. Patient-level data were used to analyze patient mortality from all hospitals across England for 3 conditions included in the program and 6 conditions not included in the program for 18 months before and 18 months after the introduction of the program. The Advancing Quality program was the first hospital-based pay-for-performance program to be introduced in England. Hospitals were required to collect and submit data on 28 quality measures covering acute myocardial infarction, coronary artery bypass grafting, heart failure, hip and knee surgery, and pneumonia. At the end of the first year, hospitals that reported quality scores in the top and second quartiles received bonuses. For the next 6 months, the reward system changed so that bonuses could be earned on the basis of 3 criteria, attainment, improvement, and achievement, with their performance during the second year compared with the first year. Thereafter, the program was included in a pay-for-performance program that applied across all of England and involved withholding of payments rather than bonuses. Patient-level data were obtained for all patients treated for 1 of 3 conditions included in the program: acute myocardial infarction, heart failure, and pneumonia. All deaths that occurred within 30 days after admission were included in the analysis. Equivalent data were obtained for patients admitted for 6 diagnoses not included in the program (acute renal failure, alcoholic liver disease, intracranial injury, paralytic ileus and intestinal obstruction without hernia, pulmonary embolism, and duodenal ulcer). The 3-year period (2007–2010) included 18 months before the program’s introduction and the first 18 months of its operation. The final sample included 410,384 patients with pneumonia, 201,003 patients with heart failure, 245,187 patients with acute myocardial infarction, and 241,009 patients with conditions not included in the program. Between-region and within-region difference-in-differences analyses were used to compare changes in mortality over time between the northwest region and the rest of England for conditions included or not included in the program. Each analysis included an interaction term between the intervention group and the period after the implementation. For all conditions, patients in the northwest region were slightly younger but had more coexisting conditions. Similar changes over time in patient volumes and patient characteristics were observed in both areas. Risk-adjusted mortality for all the conditions decreased over the 3 years in the northwest region and the rest of England. The reduction in mortality for conditions included in the program was 21.9% to 20.1% in the northwest region compared with 20.2% to 19.3% in the rest of the country. As compared with overall mortality for conditions not included in the program within the northwest region (within-region difference-in-differences analysis), a significantly greater reduction (0.9 percentage points) in overall mortality was seen for conditions included in the program, with a significant reduction only for pneumonia. The between-region difference-in-differences analysis found a significantly greater reduction of 0.9 percentage points in overall mortality in the northwest region, with individually significant reductions only for pneumonia. Combining these 2 methods in the triple-difference analysis suggested a greater overall reduction in mortality of 1.3 percentage points in the northwest region. This is a relative rate reduction of 6% and, during the 18-month period, equates to a reduction of 890 deaths in the total population of 70,644 patients with these conditions in the northwest region of England. The reduction in mortality for conditions not included in the program did not differ significantly between the 2 geographical areas. Risk-adjusted mortality for the conditions not included in the program decreased by similar amounts in the studied regions. No significant changes in the proportion of patients discharged to care institutions were noted, and all differences were smaller than 0.3 percentage points. In response to the program, participating hospitals adopted a range of quality improvement strategies. Although this program was similar to an initiative in the United States, the different results indicate that the context and implementation of such incentive programs have a close association with their outcomes. The possibility exists that incentives can have an impact on mortality.
- This paper describes the process of inducting theory using case studies from specifying the research questions to reaching closure. Some features of the process, such as problem definition and construct validation, are similar to hypothesis-testing research. Others, such as within-case analysis and replication logic, are unique to the inductive, case-oriented process. Overall, the process described here is highly iterative and tightly linked to data. This research approach is especially appropriate in new topic areas. The resultant theory is often novel, testable, and empirically valid. Finally, framebreaking insights, the tests of good theory (e.g., parsimony, logical coherence), and convincing grounding in the evidence are the key criteria for evaluating this type of research.
Brigham and Women’s Hospital (BWH) began Patient Safety Leadership WalkRounds™ in January 2001; its experience, along with that of three other Partner Healthcare hospitals, is reported.
In various attempts to contain healthcare costs and improve quality, many governments have explored new ways of controlling doctors’ resource use and practice (Kitchener 2000). A common approach has involved adopting ‘new public management’ (NPM) techniques such as the use of performance indicators (PIs) (Pollitt and Bouckaert 2000). While studies have typically concentrated on issues such as doctors’ autonomy (Harrison 1999), analyses of other professional work settings have used models of work control as the primary unit of analysis (Hoggett 1996; Kitchener 2000; Scott 1982). This paper extends that line of enquiry by adapting Kitchener et al. (2005) typology of American physician control models to frame a study of English general practitioners (GPs), a section of the medical profession which has experienced significant recent managerial reforms. The main aims are to theoretically elaborate (refine, extend, specify) Kitchener and colleagues’ typology and advance understandings of work control in the focal field (Vaughan 1992).
A questionnaire was distributed to all patients undergoing an elective otolaryngology procedure during a two-week period. The "sign in" was performed as per the instructional video on the National Patient Safety Agency website. Certain questions e.g. anticipated blood loss and risk of aspiration, increased anxiety levels of some patients prior to anaesthesia induction. Consequently, the "sign in" was modified so that the anxiety-provoking questions were discussed prior to the arrival of the patient. The questionnaire was distributed for another two-week period - the "sign in" did not increase anxiety levels in any of these patients. A simple modification of the timing of asking certain questions removed this anxiety and improved the patient journey experience through our operating department.
A small percentage of patients die during hospitalization or shortly thereafter, and it is widely believed that more or better nursing care could prevent some of these deaths. The author systematically reviewed the evidence about nurse staffing ratios and in-hospital death through September 2012. From 550 titles, 87 articles were reviewed and 15 new studies that augmented the 2 existing reviews were selected. The strongest evidence supporting a causal relationship between higher nurse staffing levels and decreased inpatient mortality comes from a longitudinal study in a single hospital that carefully accounted for nurse staffing and patient comorbid conditions and a meta-analysis that found a "dose-response relationship" in observational studies of nurse staffing and death. No studies reported any serious harms associated with an increase in nurse staffing. Limiting any stronger conclusions is the lack of an evaluation of an intervention to increase nurse staffing ratios. The formal costs of increasing the nurse-patient ratio cannot be calculated because there has been no evaluation of an intentional change in nurse staffing to improve patient outcomes. Ann Intern Med. 2013;158:404-409. www.annals.org
Expanding the traditional thinking behind quality.
Background: Medication-related adverse events (MRAEs) form a large proportion of all adverse events in hospitalized patients and are associated with considerable preventable harm. Detailed information on harm related to drugs administered during hospitalization is scarce. Knowledge of the nature and preventability of MRAEs is needed to prioritize and improve medication-related patient safety. Objective: To provide information on the nature, consequences and preventability of MRAEs occurring during hospitalization in the Netherlands. Study Design: Analysis of MRAEs identified in a retrospective chart review of patients hospitalized during 2004. Methods: The records of 7889 patients admitted to 21 hospitals in 2004 were reviewed by trained nurses and physicians using a three-stage process. For each hospital, patient records of 200 discharged and 200 deceased patients were randomly selected and reviewed. For each patient record, characteristics of the patient and the admission were collected. After identification of an MRAE the physician reviewers determined the type, severity, preventability, drug category and excess length of stay associated with the MRAE. Data on additional interventions or procedures related to MRAEs were obtained by linking our data to the national hospital registration database. The excess length of stay and the additional medical procedures were multiplied by unit costs to estimate the total excess direct medical costs associated with the MRAE. Results: In total, 148 MRAEs occurred in 140 hospital admissions. The incidence of MRAEs was 0.9% (95% CI 0.7, 1.2) and the incidence of preventable MRAEs was 0.2% (95% Cl 0.1, 0.4) per hospital admission. The majority of non-preventable MRAEs were adverse drug reactions caused by cancer chemotherapy. Preventable MRAEs were most often found in relation to anticoagulant treatment administered in combination with NSAIDs. Both non-preventable and preventable MRAEs resulted in considerable excess length of hospital stay and costs. On average, MRAEs resulted in an excess length of stay of 6.2 days (95% CI 3.6, 8.8) and average additional costs of 2507 (95% CI 1520, 3773). Conclusions: This study was the first to provide detailed information on MRAEs during hospital admissions in the Netherlands, which were associated with both considerable patient harm and additional medical costs. To increase patient safety, interventions need to be developed that reduce the burden of MRAEs. These interventions should target the areas with the highest risk of MRAEs, notably antibacterials, cancer treatment, anticoagulant treatment and drug therapy in elderly patients.
Learn how to place communication and participation at the heart of evidence-based healthcare The Knowledgeable Patient: Communication and Participation in Health sits at the forefront of the challenging, changing 21st century landscape. The 'knowledgeable patient' as an individual can take many forms: patient, family carer, consumer advocate, or member of the public interested in health issues. In each of these roles, knowledgeable patients interact with health professionals by asking questions about the evidence for treatment, seeking support, exchanging views, and contributing experiences and new ideas on how to improve the health system. Drawing from several research paradigms, The Knowledgeable Patient is an essential guide to a new era of complex healthcare. Integrating consumer stories and evidence from systematic reviews, it examines key communication and participation issues in a range of contexts, including: • surgery • safe medicine use • chronic disease self management • the complexity of multimorbidity • notification of rare disease risk. The Knowledgeable Patient is international in scope with researched examples spanning living in the community, health service treatment, governance, and policy making. It provides health professionals with new ideas, concepts, evidence, and practical tools to understand the central role of communication and participation to a well-functioning health system. It is an ideal reference for undergraduate and postgraduate students studying the health sciences. Watch a video about The Knowledgeable Patient: Communication and Participation in Health from the author, Sophie Hill: bit.ly/xNYCqG.
Introduction: Patient safety in surgery is the second Global Challenge of the World Health Organization, as 25% of hospitalizations surgical complications are related to technical errors. Up to 70% of adverse events are considered preventable, for this reason a checklist is created for safe surgery to reinforce safety practices. Objective: To determine the level of compliance and the factors influencing the implementation of the checklist. Methods: A descriptive, prospective, transversal study was conducted in May-August 2010. Convenience sample included all surgical event (n = 326) and professional staff at the operating room (n = 93). Checklist was performed with 25 items with dichotomous scale to determine level and compliance factors, feasibility, correct filling, labeling and surgical pause and perceived benefits to avoid adverse events. Excel database analyzed by frequencies, percentages and measures of central tendency. Results: The level of compliance is 87.97% of the checklist. Failure was identified in marking the surgical site (9.6%); verbal reporting of special considerations and critical situations in surgery (50.6%); aspects of recovery (41.0%). 91.8% of staff considers that the list is viable, for 86.3% it provides some benefit and 91.2% believe that it avoids adverse events. Conclusions: The low level of compliance is because the process is at an early stage of implementation, which also involves four health professionals generating lack of continuity in the correct filling of the safe surgery checklist.
Whether at work or home, quality improvement involves problem solving and learning. The plan-do-study-act (PDSA) cycle is a good generic model of how these activities take place: in the plan phase, a plan is developed to determine what changes and resources are needed to solve the problem; in the do phase, the plan or experiment is carried out; in the study phase, the results are studied; and in the act phase, action is taken based on what was learned. With these, a new cycle of learning is started. Any problem-solving effort involves multiple cycles of PDSA and each cycle leads to new knowledge.
There is a growing conflict between modern and postmodern social theorists. The latter reject modern approaches as economistic, essentialist and often leading to authoritarian policies. Modernists criticize postmodern approaches for their rejection of holistic conceptual frameworks which facilitate an overall picture of how social wholes (organizations, communities, nation-states, etc.) are constituted, reproduced and transformed. They believe the rejection of holistic methodologies leads to social myopia - a refusal to explore critically the type of broad problems that classical sociology deals with. This book attempts to bridge the divide between these two conflicting perspectives and proposes a novel holistic framework which is neither reductionist/economistic nor essentialist. Modern and Postmodern Social Theorizing will appeal to scholars and students of social theory and of social sciences in general.
How do we reflect upon ourselves and our concerns in relation to society, and vice versa? Human reflexivity works through ‘internal conversations’ using language, but also emotions, sensations and images. Most people acknowledge this ‘inner-dialogue’ and can report upon it. However, little research has been conducted on ‘internal conversations’ and how they mediate between our ultimate concerns and the social contexts we confront. Margaret Archer argues that reflexivity is progressively replacing routine action in late modernity, shaping how ordinary people make their way through the world. Using interviewees' life and work histories, she shows how ‘internal conversations’ guide the occupations people seek, keep or quit; their stances towards structural constraints and enablements; and their resulting patterns of social mobility. © Margaret S. Archer 2007 and Cambridge University Press, 2010.
The realist evaluation approach (Kazi, 2003) has the central aim of investigating what interventions work and in what circumstances. This approach essentially involves the systematic collection of data on 1) the client circumstances (e.g. demographic characteristics, cultural differences and needs, environments in which people live and function, and the nature of baseline target problems); 2) the dosage, duration and frequency of each intervention in relation to each client; and 3) the changes in the outcomes as observed through the repeated use of reliable outcome measures with each client. This is a mixed methods approach, blending together efficacy research and epidemiology. The research designs fall into place naturally as the practice unfolds, and data analysis methods are applied to investigate the patterns between the client specific factors, the intervention variables, and the outcomes. These methods include the development of binary logistic regression models, hierarchical linear modeling, and regression discontinuity designs. These methods help to link the outcome to the potential causal factors with or without a control group. This evidence provides information about the effectiveness of the models of intervention in terms of what works, for whom and in what contexts, at regular intervals and in real-time to influence policy and practice. Examples will be used from practice in social services in the UK, USA and Finland.
Aim. Completion of the WHO surgical safety checklist (SSC) has been mandatory since February 2010 for patients undergoing surgery in England and Wales. This audit aimed to assess whether an audit cycle with active intervention improves completion rates of the checklist. Methods. All general surgery patients undergoing emergency or elective operations were eligible. A pilot single day, cross-sectional, retrospective audit was followed by a 5-day prospective audit. Active intervention included presentations, verbal education and handouts to all key stakeholders and theatre staff. Re-audit of both prospective and retrospective arms followed. Results. There were 123 and 97 patents from the prospective and retrospective arms respectively. There was improvement in the number of absent forms following intervention, which was most pronounced in the emergency groups: 17% and 37% improvement in prospective and retrospective groups respectively. Increases in the rates of completion of all sections of the form were highest in emergency groups: 23% and 40% increase in the prospective and retrospective audits respectively. In all cases, completion rates were lower in the retrospective arms compared to the prospective rates. Conclusion. A prospective audit cycle with active intervention improves completion rates. Retrospective, cross sectional audit underestimates completion rates and should be avoided.
A central question of social theory is: How do society's objective features influence its members to reproduce or transform society through their actions? This volume examines how objective social conditioning is mediated by the subjective reflexivity of individuals. On the basis of a series of in-depth interviews, Margaret S., Archer identifies the mediatory mechanism as "internal conversations" that are expressed in forms governing agents’ responses to social conditioning, their individual patterns of social mobility, and whether or not they contribute to social stability or change.
Infections caused by multidrug resistant bacteria (MDR) pose a challenge for the German healthcare system. Basic strategies for infection prevention and control are well known; however, the prevalence of e.g. Methicillin resistant Staphylococcus aureus (MRSA) still remains on a level 20 times higher than in the Netherlands. Especially hospitals are bound to address this problem; ultimately, all healthcare- providers and authorities are obliged to manage MDR. Since healthcare infrastructure and medical treatment are interrelated, infection prevention strategies have to be established, which cross both healthcare sectors and regional borders. Efforts to optimize MDR-prevention and patient safety may benefit from the establishment of regional networks. The EurSafety Health-net project for patient safety and infection prevention was initiated on the basis of the project "EUREGIO MRSA-net" Twente/Münsterland and covers the whole Dutch-German border region. Quality-networks have been established in which e. g. representatives of hospitals, nursing homes and local health authorities cooperate in order to align infection prevention strategies. In their role as a major hub connected to the different healthcare stakeholders, the local health authorities preside over and moderate the regional networks and activities. Within this framework, synchronized quality criteria for hospitals have been elaborated. A seal of quality publicly illustrating the infection prevention measures is awarded to thosehospitals that meet the criteria. Consultation and quality audits are carried out by the local health authorities. A total of five consecutive seals of quality are planned for the future and most recently, quality criteria for nursing homes have been developed and will be implemented soon.
The vast majority of doctors behave to the highest professional standards, but a small number do not. Those who display unprofessional behaviour tend to do so recurrently and often go unchallenged, except in the most extreme cases. In North America such behaviour is termed 'disruptive' and is receiving increased attention from regulators following a clear demonstration of a link with medical errors. In the United Kingdoma small number of the most serious cases will come to the attention of the National Clinical Assessment Service (NCAS) or the General Medical Council but little attention has been paid to lower profile behavioural disturbance. Disruptive behaviour has also been demonstrated by nurses, other clinicians and managers but it is the behaviour of doctors which has been most closely linked with patient harm. In this paper we shall review the literature on disruptive behaviour by doctors and examine the evidence linking it to patient harm and unsafe working environments. We shall describe some of the programmes which have been developed in North America to deal with this and suggest ways in which these might be adapted for use in the UK.
Study objective: Resuscitation is a fast paced highly complex process which makes considerable demands on the resuscitation team; even minor errors and failures may reduce the chance of a successful outcome. Failure Mode Effects Analysis (FMEA) is a team-based, systematic proactive step-by-step process which identifies failure modes/hazards within the process which could compromise the progression and outcome of the process and highlights where improvements need to be implemented to mitigate failures from occurring. We applied FMEA to the resuscitation process and highlight specific areas within the currently accepted resuscitation protocol which require further assessment. Methods: We followed the procedure for FMEA outlined by the Joint Commission but with some modifications of the basic process. Our modified approach made use of 16 individual interviews with healthcare professionals experienced in resuscitation and focus groups in order to gain a more detailed understanding of the different perspectives on the resuscitation process. The interviews prioritised potential failures that exist in the on-ward resuscitation process which enabled the team to identify specific areas which require further assessment and improvements. Results: In total the FMEA found 28 failure modes that carry a degree of risk that require action. It was found that staff perceived failure modes that relate to the patient's airway, breathing or circulation as ones which would result in a severe effect on the patient's outcome, and those that relate to tasks involved in the running of the process were often perceived as likely to occur. Conclusion: The modified FMEA approach proved practical, and was well received by clinicians within the context of resuscitation and fundamentally highlighted areas where quality improvements are necessary. Our research group and design team at the Helen Hamlyn Centre used the FMEA to develop design cues and technology innovations to address current issues of design duplicity that would be incorporated into a new 'intelligent resuscitation trolley' which we foresee will support the team by improving communication, coordination and overall efficiency.
This book completes Margaret Archer's trilogy investigating the role of reflexivity in mediating between structure and agency. What do young people want from life? Using analysis of family experiences and life histories, her argument respects the properties and powers of both and presents the 'internal conversation' as the site of their interplay. In unpacking what 'social conditioning' means, Archer demonstrates the usefulness of 'relational realism'. She advances a new theory of relational socialisation, appropriate to the 'mixed messages' conveyed in families that are rarely normatively consensual and thus cannot provide clear guidelines for action. Life-histories are analysed to explain the making and breaking of different modes of reflexivity. Different modalities have been dominant from early societies to the present and the author argues that modernity is slowly ceding place to a 'morphogenetic society' as meta-reflexivity now begins to predominate, at least amongst educated young people.
We address the co-evolution of language and material practices during institutionalization by proposing a tropological model of institutionalization that integrates linguistic and practice-oriented approaches into a four-stage sequence: Metaphor enables members to inaugurate institutional change by inspiring and energizing initial movement. Members use metonymy to operationalize the emerging institution by demonstrating how it can become expected practice. Synecdoche is used to facilitate diffusion, standardizing the institution across time and space. When material practice is noticeably contrary to linguistic claims, however, members use irony to bring about deinstitutionalization and generate another inaugurating metaphor. The model further proposes that ritualized actions dramatize each trope, highlighting its symbolic meaning and embedding distinct material practices that serve both to institutionalize the practice and to facilitate boundary crossing to the next trope. The paper goes beyond current literature by offering an integrated theory of trope and ritual as an explanation of how institutions are simultaneously symbolic-linguistic and practice-material.
Purpose: To describe a Hospital Quality Improvement (QI) Initiative conducted through the University of Toronto Chapter of the Institute for Healthcare Improvement (IHI) Open School, which involved an interdisciplinary student team that worked on a QI project aimed at improving the efficiency of a core laboratory in a community hospital, and to assess the learning outcomes and student team's experience. Method: An interdisciplinary team of six students, along with a Project Sponsor and Core Laboratory staff, applied the IHI model for improvement, the Plan-Do-Study-Act cycle, to execute the QI project. The learning outcomes and student team's experience were assessed using a framework of factors influencing the successful implementation of quality of care or patient safety curricula identified by Wong et al.1 Results: The target for the QI project was to reduce turnaround times for manual differentials of abnormal complete blood counts (CBCs) to below two hours. A number of process changes were trialed for one day, and turnaround time data was collected both on the trial day and for a month following the implementation of the changes. Analysis of the turnaround times after the implementation were favourable and showed an increase in the proportion of samples processed within the target time frame of two hours, and a decrease in the number of samples processed out of sequence. The student team was able to develop a feasible solution to an identified gap between current and ideal clinical practices. Management, team, and learning environment factors contributed to the success of the project. Conclusions: From this team's experience, QI projects appear to be a useful exercise for students to apply QI models and to become comfortable with using QI methods. They are an effective method for providing students with interdisciplinary learning opportunities. Further, the work done by students on these projects has the potential to create useful and feasible solutions.
This article explores how hybrid organizations, which incorporate competing institutional logics, internally manage the logics that they embody. Relying on an inductive comparative case study of four work integration social enterprises embedded in competing social welfare and commercial logics, we show that, instead of adopting strategies of decoupling or compromising, as the literature typically suggests, these organizations selectively coupled intact elements prescribed by each logic. This strategy allowed them to project legitimacy to external stakeholders without having to engage in costly deceptions or negotiations. We further identify a specific hybridization pattern that we refer to as "Trojan horse," whereby organizations that entered the work integration field with low legitimacy because of their embeddedness in the commercial logic strategically incorporated elements from the social welfare logic in an attempt to gain legitimacy and acceptance. Surprisingly, they did so more than comparable organizations originating from the social welfare logic. These findings suggest that, when lacking legitimacy in a given field, hybrids may manipulate the templates provided by the multiple logics in which they are embedded in an attempt to gain acceptance. Overall, our findings contribute to a better understanding of how organizations can survive and thrive when embedded in pluralistic institutional environments.
Background
Antibiotic stewardship programs have been shown to reduce inappropriate institutional antibiotic use. There is no consensus on the strategies, e.g. formulary restrictions, that best improve appropriate use and reduce misuse of antibiotics.AimTo identify facilitators and barriers to compliance with an institutional antibiotic prescribing policy and to compare policymakers' perceptions about the facilitators and barriers that influence compliance with those held by prescribers.Method5 antimicrobial stewardship committee members (policymakers) and 15 prescribers from a large Sydney hospital participated in a semi-structured interview. To gauge prescribers' knowledge of the institutional antibiotic policy, case scenarios were included in the interviews with prescribers. Interviews were continued until data saturation was reached. Recurrent themes were analysed and interpreted in terms of a well-known conceptual framework of barriers to physician adherence to guidelines.ResultsAntimicrobial stewardship committee members identified lack of knowledge as the main barrier to compliance with the antibiotic prescribing policy. Despite reporting that they were aware of and agreed with the antibiotic prescribing policy, most prescribers did not comply with the policy and referred to clinical information sources when completing the case scenarios. Organisational hierarchies were frequently reported as a barrier by both participant groups. While prescribers considered inapplicability of the antibiotic prescribing policy as an important barrier, antimicrobial stewardship committee members attributed non-compliance to the policy to prescriber autonomy and personal experience.Conclusion
We identified several barriers to compliance with the antibiotic prescribing policy, such as poor knowledge of policy specifics and medical hierarchies. Involving prescribers in policy development, giving them feedback about their prescribing, and improving existing collaboration and decision support platforms may further improve judicious antibiotic use.
We use a dialectical perspective to provide a unique framework for understanding institutional change that more fully captures its totalistic, historical, and dynamic nature, as well as fundamentally resolves a theoretical dilemma of institutional theory: the relative swing between agency and embeddedness. In this framework institutional change is understood as an outcome of the dynamic interactions between two institutional by-products: institutional contradictions and human praxis. In particular, we depict praxis - agency embedded in a totality of multiple levels of interpenetrating, incompatible institutional arrangements (centradictions)-as an essential driving force of institutional change.
The creation of new roles commonly threatens the power and status of elite professionals through the substitution of their labour. In this paper we examine the institutional work carried out by elite professionals to maintain their professional dominance when threatened. Drawing on 11 case sites from the English National Health Service (NHS) where new nursing or medical roles have been introduced, threatening the power and status of specialist doctors, we observed the following. First, the professional elite respond through institutional work to supplant threat of substitution with the opportunity for them to delegate routine tasks to other actors and maintain existing resource and control arrangements over the delivery of services in a way that enhances elite professionals' status. Second, other professionals outside the professional elite, but relatively powerful within their own professional group, are co-opted by the professional elite to engage in institutional work to maintain existing arrangements. Our work extends Lawrence and Suddaby's typology of institutional work in three ways. First, we reveal how different types of institutional work interact, and how different types of institutional work cross categories of creating or maintaining institutions. Second, we show how an actor's social position or status, both intra-professionally as well as inter-professionally, in the institutional field frame the institutional work they engage in. Third, the institutional work of 'theorizing' by professional elites appears particularly significant, specifically the focus of the institutional work to invoke the concept of 'risk' associated with any change in service delivery, which maintains the model of medical professionalism.
Purpose
The purpose of this paper is to briefly review the history of healthcare‐associated infection (HAI) prevention programs in the USA since the early 1970s until today, and provide suggestions how other countries (and Canada specifically) may learn from this experience to accelerate HAI prevention and patient safety improvements in their counties.
Design/methodology/approach
The paper is a narrative review of literature and personal experience.
Findings
US hospitals have had healthcare‐associated infection (HAI) prevention programs, including surveillance for selected HAIs, since the late 1960s‐early 1970s. Such programs began with active surveillance for HAIs based upon the Centers for Disease Control and Prevention's (CDCs) National Nosocomial Infections Surveillance (NNIS) system. This system included standardized definitions and surveillance protocols. Since the 1980s, the CDC has developed HAI prevention guidelines, with categorized recommendations for HAI prevention. In the early 2000s, the Institute of Medicine published a report outlining the harm caused by HAIs. This led to increased attention to HAI prevention by an increasingly wide variety of organizations. The Joint Commission and the Centers for Medicare and Medicaid Services (CMS) initiated HAI prevention efforts. Many studies documented the failure of hospitals to fully implement evidence‐based practices. The increased attention to HAIs and their morbidity and mortality led to media reports and ultimately an initiative by the Consumer's Union for mandatory reporting of HAI rates by hospitals in all states. Subsequently, the CMS introduced decreased reimbursement for the additional costs directly related to HAIs (and other critical incidents) and linkage of reimbursement levels to hospital HAI rates. Together, mandatory reporting and reduced reimbursement for HAIs has led hospital executives to focus more attention on infection control programs to decrease HAI rates. Progress on preventing HAIs seems to be related to standardizing evidence‐based HAI prevention bundles, mandatory reporting, and paying for performance (or not paying for preventable HAI complications). Given that voluntary HAI prevention programs have existed since the 1970s, it appears that regulation, reporting, and decreased reimbursement has resulted in more rapid implementation of HAI prevention programs and improved patient safety.
Practical implications
The different major activities enhancing HAI prevention in the USA are outlined in an historic context.
Originality/value
Understanding the history of progress in hospital infection control efforts provides an essential perspective for policy makers and for the interdisciplinary team required to evaluate HAI mandatory public reporting in a comprehensive manner.
Background
Evidence indicates that improved hand hygiene compliance can lead to reductions in healthcare associated infection. However, there are few papers that clearly document the observation method used to collect the hand hygiene compliance data. This article describes the Hand Hygiene Australia 5 Moments for Hand Hygiene observation method in detail.
Methods
The Australian Commission for Safety and Quality in Health Care funded Hand Hygiene Australia (HHA) to implement the National Hand Hygiene Initiative (NHHI) to improve hand hygiene compliance (HHC) and establish a national validated system of HHC auditing. Based on the World Health Organisation (WHO) World Alliance for Patient Safety campaign ‘Clean Care is Safer Care’, HHA adapted the WHO hand hygiene compliance data collection form to suit Australian healthcare facilities.
Results
Hand Hygiene Australia developed a standardised approach to direct observation of HHC of healthcare workers by developing a uniform suite of tools and a data management system for accurate data collection and report generation.
Conclusion
Implementation of the HHA 5 Moments HHC audit method has facilitated standardised, reliable and meaningful collection of hand hygiene compliance data that is driving HHC improvement across many different healthcare settings around Australia.