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ENHANCING THE QUALITY AND SAFETY OF SWISS HEALTHCARE

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Abstract

In mid-2018 the Federal Office of Public Health (FOPH) commissioned a Swiss National Report on quality and safety in healthcare. The report, based on two literature reviews and 26 short reports, was written by Charles Vincent and Anthony Staines.
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... In Switzerland, as in many other countries, healthcare is under increased scrutiny to enhance the quality and safety of patients. While quality measures for hospital-based care are well established and publicly reported, reliable and accessible information on the quality of home care is lacking [1]. This gap is ever more pronounced, because home care is becoming increasingly important due to an ageing population and a rise in prevalence of chronic conditions. ...
... The ranking presents the relative QI performance among the HCOs and with respect to the client population mean (total QI rate). An established benchmark of best practice or standards for quality of home care for the QI bladder incontinence are currently lacking in Switzerland and also internationally [1,42]. Thus, it remains unclear, even after risk-adjustment, which QI rate corresponds to high quality care or potential care problems. ...
... While this study has shown that the database HCD yields the potential for thorough risk adjustment of the RAI-HC QIs, lack of routine data of high quality are crucial limitations [1]. Due to the implementation of the interRAI-HC in Switzerland (longer version of the RAI-HC) in 2020, an increase in HCD data suppliers and improved data quality are expected. ...
Article
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Quality indicators (QIs) based on the Resident Assessment Instrument-Home Care (RAI-HC) offer the opportunity to assess home care quality and compare home care organizations’ (HCOs) performance. For fair comparisons, providers’ QI rates must be risk-adjusted to control for different case-mix. The study’s objectives were to develop a risk adjustment model for worsening or onset of urinary incontinence (UI), measured with the RAI-HC QI bladder incontinence, using the database HomeCareData and to assess the impact of risk adjustment on quality rankings of HCOs. Risk factors of UI were identified in the scientific literature, and multivariable logistic regression was used to develop the risk adjustment model. The observed and risk-adjusted QI rates were calculated on organization level, uncertainty addressed by nonparametric bootstrapping. The differences between observed and risk-adjusted QI rates were graphically assessed with a Bland-Altman plot and the impact of risk adjustment examined by HCOs tertile ranking changes. 12,652 clients from 76 Swiss HCOs aged 18 years and older receiving home care between 1 January 2017, and 31 December 2018, were included. Eight risk factors were significantly associated with worsening or onset of UI: older age, female sex, obesity, impairment in cognition, impairment in hygiene, impairment in bathing, unsteady gait, and hospitalization. The adjustment model showed fair discrimination power and had a considerable effect on tertile ranking: 14 (20%) of 70 HCOs shifted to another tertile after risk adjustment. The study showed the importance of risk adjustment for fair comparisons of the quality of UI care between HCOs in Switzerland.
... Demographic changes are increasing the demand for hospital services (1), while concurrently growing cost pressures and a lack of qualified staff threaten patient safety (2). To monitor patient safety and provide a data basis for comparing hospital and quality improvement, national quality measurements are carried out annually in Switzerland. ...
... Thus, representatives from 3 hospitals (incl. nursing experts and managers, IT specialists) and 7 other stakeholders (from health insurers [1], the hospital association [1], national regulatory authorities [3] and regional regulatory authorities [2]) participated in the project. ...
Chapter
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National quality measurements with risk-adjusted provider comparison in health care nowadays usually require administrative or clinically measured data. However, both data sources have their limitations. Due to the digitalisation of institutions and the resulting switch to electronic medical records, the question arises as to whether these data can be made usable for risk-adjusted quality comparisons from both a content and a technical point of view. We found that most of the relevant information can be exported with little effort from the electronic medical records. In using this data source an even more sophisticated operationalization of the data of interest is needed.
... patient outcomes [16]). Similarly, healthcare data transparency is still in its infancy [17]. ...
... However, due to the lack and/or the opacity of data (e.g. quality of services, negotiation of payment rates) [17,47], assessing this performance remains a challenge. ...
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Introduction: Switzerland's fragmented healthcare system mirrors its federal structure and mix of cultures and languages. Although the Swiss have a higher life expectancy than most of their neighbours, their healthcare system faces similar challenges that call for more integrated care (IC). Aim/method: This article aims to provide insight into the specificities of and latest developments in Switzerland's healthcare system and how they may have influenced the development and implementation of IC there. Description/discussion: The number of local IC initiatives has been growing steadily for 20 years. With a certain lag, various policies supporting IC have been established. Among them, a recent democratic debate on the federal mandatory health insurance law could either induce a radical move towards centralised support for IC or continue to support scattered local IC initiatives. Conclusion: In the future, Switzerland's healthcare system will probably navigate between local IC initiatives and centralised, federal support for IC initiatives. This will be the reflection of a very Swiss way forward in a world without clear evidence on whether centralised or decentralised initiatives are more successful at developing IC.
... However, detailed epidemiological data about the use of different types of aftercare for substance use disorders in Switzerland is lacking. Moreover, a recently published national report on the Swiss healthcare system criticised the lack of data about quality and efficacy of treatment in the mental healthcare sector [24]. It is therefore unknown whether patients in need of a higher level of aftercare finally receive the appropriate treatment, and whether patients treated in rather high-threshold rehabilitation programmes would likewise benefit from less intense aftercare. ...
Article
Aims of the study: Aftercare following inpatient withdrawal treatment improves the prognosis and prevents future readmissions in patients with substance use disorders. According to the stepped care approach, the setting and intensity of aftercare should be adjusted to the patients' specific needs and resources. This study evaluated the real-life referral to different types of aftercare in Switzerland and the rate of inpatient readmission within a 1-year follow-up. Methods: All substance use disorder patients admitted for inpatient withdrawal treatment in a Swiss psychiatric hospital between January and December 2016 (n = 497) were included in this retrospective study. Clinical and sociodemographic characteristics were extracted from the electronic medical records and their impact on the likelihood of being referred to a particular type of aftercare (general practitioner, psychiatric outpatient care, psychiatric day clinic, inpatient rehabilitation programme) was evaluated. For each type of referral, we determined the readmission rate within one year after discharge. Results: In the sample of substance use disorder patients (mean age 41 years; 69% male), alcohol use disorder was by far the most frequent substance use disorder. Most patients were referred to psychiatric outpatient care (39.8%), followed by a general practitioner (31.0%), inpatient rehabilitation (19.3%) and psychiatric day clinic (9.9%). Patient characteristics that point to an unfavourable course of disease, including higher symptom severity, history of more than two previous admissions, compulsory admission and treatment discontinuation, were associated with a higher likelihood to be referred to lower-level aftercare (general practitioner, psychiatric outpatient care), whereas patients with lower symptom severity, fewer than two previous admissions, voluntary admission and regular discharge were more likely to be referred to high-intensity aftercare (psychiatric day clinic, inpatient rehabilitation). The readmission rate after one year did not differ between the different settings of aftercare (range 40.4-42.9%). Conclusions: The findings of this study suggest that patients suffering from severe substance use disorders and/or from an unfavourable course of disease who would benefit from a more intensive aftercare setting, such as psychiatric day clinics or inpatient rehabilitation programs, might be under-treated, whereas patients with a rather favourable prognosis might similarly benefit from a less intensive treatment setting, such as psychiatric outpatient care. Regarding the comparable readmission rates, we recommend considering more efficient resource management by promoting stepped care approaches for substance use disorders and establishing standardised placement criteria in Switzerland.
... The Swiss federal legislation on health insurance was revised in 2019 proposing a national programme to improve the quality and safety of provided healthcare [7]. A recent national report showed insufficient availability of information and a lack of standardized quality indicators [8], which are key for successful systematic healthcare quality monitoring [9]. Specifically, patient-reported outcome measures (PROMs) are of growing importance in Switzerland and internationally [10], and as a tool for quality assurance and healthcare quality improvement [11]. ...
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Background The Balgrist University Hospital in Zurich, Switzerland, is an academic hospital focused on musculoskeletal disorders. An integrated chiropractic medicine clinic provides chiropractic care to a broad patient population. This health services research study aims to advance understanding of chiropractic healthcare service for quality assurance and healthcare quality improvement. Methods We performed an observational clinical cohort study at the Balgrist chiropractic medicine outpatient clinic in 2019. The records of all patients with initial visits or returning initial visits (> 3 months since last visit) and their subsequent visits from January 1, 2019, to December 31, 2019, were used to create the study dataset. Data collected included demographic characteristics, diagnoses, imaging data, conservative treatments, surgeries, and other clinical care data. Descriptive statistics were used to summarize data. Results 1844 distinct patients (52% female, mean age 48 ± 17 years) were eligible and included in the study. 1742 patients had a single initial visit, 101 had 2 initial visits, and 1 patient had 3 initial visits during the study period (total of 1947 initial visit records). The most common main diagnoses were low back pain (42%; 95% CI 40–46%), neck pain (22%; 20–24%), and thoracic pain (8%; 7–9%). 32% of patients presented with acute (< 4 weeks) symptoms, 11% subacute (4–12 weeks), and 57% chronic (> 12 weeks). Patients had a median of 5 chiropractic visits during their episode of care within a median of 28 days duration. Only 49% (95% CI 47–52%) of patient records had a clinical outcome that was extractable from routine clinical documentation in the hospital information system. Conclusion This health services study provides an initial understanding of patient characteristics and healthcare delivered in a Swiss academic hospital chiropractic outpatient setting and areas for improved clinical data quality assurance. A more concerted effort to systematically collect patient reported outcome measures would be a worthwhile healthcare quality improvement initiative.
... L'EBCD est basé sur le design thinking, une méthode participative née à Stanford (USA) dans les années 1980(Faste, 1987 pour percevoir les besoins dans les processus d'innovation, notamment dans l'industrie, et encore très en vogue de nos jours dans de multiples domaines. Le rapport national de 2019 sur la qualité et la sécurité des soins en Suisse (Vincent and Staines, 2019) Au niveau macro, des représentant-e-s de la population et des patient-e-s sont de plus en plus souvent impliqué-e-s dans la définition des politiques de santé, par exemple au Royaume-Uni (Florin and Dixon, 2004) ou en France (Bréchat et al., 2010;Letourmy and Naiditch, 2009), à tous les échelons décisionnels de ce qu'on appelle aujourd'hui la « démocratie sanitaire » : « La représentation des usagers s'organise dans cinq champs définis par la participation à la gouvernance du système de santé : l'implication dans les conseils d'administration (CA) et dans les conférences de santé, le soutien aux usagers, la défense des droits et la promotion des droits » (Sebai, 2018 p. 625). La figure 7 énumère les rôles possibles de cette représentation. ...
Thesis
Pourquoi et comment déployer le partenariat de soins entre patient-e-s et professionnel-le-s au sein du système régional de santé ? De plus en plus, on donne la parole aux patient-e-s. C’est très bien ! Et de plus en plus, les patient-e-s âgé-e-s, les malades chroniques et leurs proches nous disent : « Je ne veux pas refaire plusieurs fois les mêmes examens, ni raconter inlassablement mon parcours à des nouvelles personnes ! » « J’aimerais que le médecin de ma mère ait accès à tous ses traitements, et qu’il puisse les coordonner ». « J’ai rédigé un projet de soins anticipé, mais comment être sûr qu’il sera respecté si je perds mon discernement ou si je suis admis aux urgences ? » Et alors ? Pourra-t-on encore longtemps leur répondre : « Désolé, mais ça ne va pas être possible » ? « Chaque structure de soins fonctionne avec ses propres règles, ses processus, son financement et ses tarifs ; impossible à coordonner davantage » ? « Nous travaillons depuis 25 ans sur le dossier électronique du patient mais ça ne marche toujours pas… » ? En Suisse, l’un des pays les plus riches du monde, les soins sont globalement d’excellente qualité. Mais leur coordination reste très aléatoire. Au nom de la liberté de choix, une majorité politique favorable à une responsabilité individuelle accrue plutôt qu’à toute régulation étatique supplémentaire s’évertue à garder bien étanches les frontières entre chaque acteur du système de santé, veillant surtout à ce que chacun d’entre eux soit profitable ! Ces personnes ne voient pas le système de santé suisse comme un bien commun qu’il faut aménager au plus près des besoins des patient-e-s et de la population, mais comme une collection de tiroirs-caisses. Le système régional de santé, tel un écosystème d’affaires, doit pourtant prendre en compte les besoins de ses « client-e-s ». Nous avons conduit une recherche-intervention sur l’introduction d’une innovation clinique et sociétale au sein du Réseau Santé Région Lausanne, et mené deux enquêtes auprès des acteurs régionaux afin de connaître leurs positions et attentes sur le partenariat de soins. Nos résultats apportent aux instances politiques, aux dirigeant-e-s des institutions de santé – publiques ou privées – ainsi qu’à tou-te-s les professionnel-le-s de la santé, des arguments et recommandations pour inclure le partenariat dans leurs stratégies respectives. Ou mieux : pour élaborer une stratégie commune en la matière. Sans oublier d’y associer les patient-e-s et leurs représentant-e-s ! Mots-clés : partenariat de soins / patient-partenaire / management de la santé / systèmes de santé / écosystèmes d’affaires / coordination des soins / soins intégrés / innovation sociale / soins anticipé
... However, Swiss hospitals only offer 18.5 training positions for the certificate of proficiency in clinical pharmacy, a postgraduate education program focusing on patient-oriented pharmaceutical activities [12]. Another reason may be that, although medication safety is gaining importance in the Swiss Federal Office of Public Health, there are no legally binding recommendations for Swiss hospitals to implement such services [49]. ...
Article
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Readmissions to the hospital are frequent after hospital discharge. Pharmacist-led interventions have been shown to reduce readmissions. The objective of this study was to describe pharmacist-led interventions to support patients' medication management at hospital discharge in Switzerland and to compare them to international guidelines. We conducted a national online survey among chief hospital pharmacists focusing on medication management at hospital discharge. To put our findings in perspective, Cochrane reviews and guidelines were searched for summarised evidence and recommendations on interventions. Based on answers in the survey, hospitals with implemented models to support patients at discharge were selected for in-depth interviews. In semi-structured interviews, they were asked to describe pharmacists' involvement in the patients' pathway throughout the hospital stay. In Swiss hospitals (n = 44 survey participants), interventions to support patients at discharge were frequently implemented, mostly "patient education" (n = 40) and "communication to primary care provider" (n = 34). These interventions were commonly recommended in guidelines. Overall, pharmacists were rarely involved in the interventions on a regular basis. When pharmacists were involved, the services were provided by hospital pharmacies or collaborating community pharmacies. In conclusion, interventions recommended in guidelines were frequently implemented in Swiss hospitals, however pharmacists were rarely involved.
Article
The Swiss healthcare system is highly decentralized, making implementation of shared decision making (SDM) and patient and public involvement (PPI) quite slow; nonetheless, change is happening. SDM is now a core communication competency for medical school graduates, as reflected by a dedicated station on the federal exam, and is endorsed by several national societies. Multiple local initiatives are contributing to international best practices, local implementation, and increased capacity. PPI is also gaining momentum, most notably in research, with the development of a national platform for clinical research and inclusion of patients in the evaluation committees for funding. The challenge now is going from example projects by motivated early adopters in academia to making SDM and PPI standard practice.
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Background The Balgrist University Hospital in Zurich, Switzerland, is an academic hospital focused on musculoskeletal (MSK) disorders. An integrated chiropractic medicine clinic provides chiropractic care to a broad patient population. Our health services research study aims to advance understanding of chiropractic health care service for quality assurance and health care quality improvement. Methods An observational clinical cohort study at the Balgrist chiropractic medicine clinic in 2019 was performed. The records of all patients with initial visits or returning initial visits (> 3 months since last visit) and their subsequent visits from January 1, 2019 to December 31, 2019, were used to create the study dataset. Data collected included demographic characteristics, diagnoses, imaging data, conservative treatments, surgeries, and other clinical care data. Descriptive statistics were used to summarize data. Results 1844 distinct patients (52% female, mean age 48 ± 17 years) were eligible and included in the study. 1742 patients had a single initial visit, 101 had 2 initial visits, and 1 patient had 3 initial visits during the study period. The most common main diagnoses were: low back pain (41%; 95% CI, 39–43%), neck pain (21%; 19–23%), and thoracic pain (8%; 7–9%). 29% had an acute (< 4 weeks) symptom duration, 10% subacute (4 to 12 weeks), and 52% chronic (> 12 weeks). Patients had a median number of 5 chiropractic visits during their episode of care, with a median care episode duration of 28 days. Only 49% (95% CI, 47–52%) of patient records had a clinical outcome that was extractable from routine clinical practice documentation retrievable from the hospital system. Conclusion Our health services research study provides an initial understanding of the patient characteristics and MSK clinical care delivered in a Swiss outpatient hospital setting and areas for clinical data quality assurance. Deeper insights into health care services and outcomes will help to facilitate a health quality improvement initiative by identifying clinical data and health care quality gaps, and establishing overall aims and targets for improvement.
Article
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Objective Medication reconciliation (MedRec) is a relevant safety procedure in medication management at transitions of care. The aim of this study was to evaluate the impact of MedRec, including a best possible medication history (BPMH) compared with a standard medication history in patients admitted to an internal medicine ward. Design Prospective interventional study. Data were analysed using descriptive statistics followed by univariate and multivariate Poisson regression models and a zero-inflated Poisson regression model. Setting Internal medicine ward in a secondary care hospital in Southern Switzerland. Participants The first 100 consecutive patients admitted in an internal medicine ward. Primary and secondary outcome measures Medication discrepancies between the medication list obtained by the physician and that obtained by a pharmacist according to a systematic approach (BPMH) were collected, quantified and assessed by an expert panel that assigned a severity score. The same procedure was applied to discrepancies regarding allergies. Predicting factors for medication discrepancies were identified. Results The median of medications per patient was 8 after standard medication history and 11 after BPMH. Total admission discrepancies were 524 (5.24 discrepancies per patient) with at least 1 discrepancy per patient. For 47 patients, at least one discrepancy was classified as clinically relevant. Discrepancies were classified as significant and serious in 19% and 2% of cases, respectively. Furthermore, 67% of the discrepancies were detected during the interview conducted by the pharmacist with the patients and/or their caregivers. The number of drugs used and the autonomous management of home therapy were associated with an increased number of clinically relevant discrepancies in a multivariable Poisson regression model. Conclusion Even in an advanced healthcare system, a standardised MedRec process including a BPMH represents an important strategy that may contribute to avoid a notable number of clinically relevant discrepancies and potential adverse drug events.
Article
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Quality circles or peer review groups, and similar structured small groups of 6–12 health care professionals meet regularly across Europe to reflect on and improve their standard practice. There is debate over their effectiveness in primary health care, especially over their potential to change practitioners’ behaviour. Despite their popularity, we could not identify broad surveys of the literature on quality circles in a primary care context. Our scoping review was intended to identify possible definitions of quality circles, their origins, and reported effectiveness in primary health care, and to identify gaps in our knowledge. We searched appropriate databases and included any relevant paper on quality circles published until December 2017. We then compared information we found in the articles to that we found in books and on websites. Our search returned 7824 citations, from which we identified 82 background papers and 58 papers about quality circles. We found that they originated in manufacturing industry and that many countries adopted them for primary health care to continuously improve medical education, professional development, and quality of care. Quality circles are not standardized and their techniques are complex. We identified 19 papers that described individual studies, one paper that summarized 3 studies, and 1 systematic review that suggested that quality circles can effectively change behaviour, though effect sizes varied, depending on topic and context. Studies also suggested participation may affirm self-esteem and increase professional confidence. Because reports of the effect of quality circles on behaviour are variable, we recommend theory-driven research approaches to analyse and improve the effectiveness of this complex intervention.
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Importance Reducing wrong-site surgery is fundamental to safe, high-quality care. This is a follow-up study examining 8 years of reported surgical adverse events and root causes in the nation’s largest integrated health care system. Objectives To provide a follow-up description of incorrect surgical procedures reported from 2010 to 2017 from US Veterans Health Administration (VHA) medical centers, compared with the previous studies of 2001 to 2006 and 2006 to 2009, and to recommend actions for future prevention of such events. Design, Setting, and Participants This quality improvement study describes patient safety adverse events and close calls reported from 86 VHA medical centers from the approximately 130 VHA facilities with a surgical program. The surgical procedures and programs vary in size and complexity from small rural centers to large, complex urban facilities. Procedures occurring between January 1, 2010, and December 31, 2017, were included. Data analysis took place in 2018. Main Outcomes and Measures The categories of incorrect procedure types were wrong patient, side, site (including wrong-level spine), procedure, or implant. Events included those in or out of the operating room, adverse events or close calls, surgical specialty, and harm. These results were compared with the previous studies of VHA-reported wrong-site surgery (2001-2006 and 2006-2009). Results Our review produced 483 reports (277 adverse events and 206 close calls). The rate of in–operating room (in-OR) reported adverse events with harm has continued to trend downward from 1.74 to 0.47 reported adverse events with harm per 100 000 procedures between 2000 and 2017 based on 6 591 986 in-OR procedures. When in-OR events were examined by discipline as a rate, dentistry had 1.54, neurosurgery had 1.53, and ophthalmology had 1.06 reported in-OR adverse events per 10 000 cases. The overall VHA in-OR rate for adverse events during 2010 to 2017 was 0.53 per 10 000 procedures based on 3 234 514 in-OR procedures. The most common root cause for adverse events was related to issues in performing a comprehensive time-out (28.4%). In these cases, the time-out either was conducted incorrectly or was incomplete in some way. Conclusions and Relevance Over the period studied, the VHA identified a decrease in the rate of reported adverse events in the OR associated with harm and continued reporting of adverse event close calls. Organizational efforts continue to examine root cause analysis reports, promulgate lessons learned, and enhance policy to promote a culture and behavior that minimizes events and is transparent in reporting occurrences.
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Background: The level of quality of care of ambulatory services in Switzerland is almost completely unknown. By adapting existing instruments to the Swiss national context, the present project aimed to define quality indicators (QI) for the measurement of quality of primary care for use on health insurance claims data. These data are pre-existing and available nationwide which provides an excellent opportunity for their use in the context of health care quality assurance. Methods: Pragmatic 6-step process based on informal consensus. Potential QI consisted of recommendations extracted from internationally accepted medical practice guidelines and pre-existing QI for primary care. An independent interdisciplinary group of experts rated potential QI based on explicit criteria related to evidence, relevance for Swiss public health, and controllability in the Swiss primary care context. Feasibility of a preliminary set of QI was tested using claims data of persons with basic mandatory health insurance with insurance at one of the largest Swiss health insurers. This test built the basis for expert consensus on the final set of QI. Results: Of 49 potential indicators, 23 were selected for feasibility testing based on claims data. The expert group consented a final set of 24 QI covering the domains general aspects/ efficiency (7 QI), drug safety (2), geriatric care (4), respiratory disease (2), diabetes (5) and cardiovascular disease (4). Conclusions: The present project provides the first nationwide applicable explicit evidence-based criteria to measure quality of care of ambulatory primary care in Switzerland. The set intends to increase transparency related to quality and variance of care in Switzerland.
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This study was conducted to investigate body mass index (BMI), levels of cholesterol and triglycerides in prison inmates at the Institution for Reform and Rehabilitation in Southern Libya to be considered as an indication about their health and the provided foods. The results of this study showed that 26.5% of BMI of the prison inmates were found to be higher than the normal levels. Generally, the average level of cholesterol and triglycerides concentrations were found to be within normal range 142.6 mg/dl and 135.4 mg/dl, respectively. The findings also established that there were a significant relationship and direct correlation between BMI levels and age and concentration of cholesterol and triglycerides levels. The results of this showed that the served foods for these prison inmates are well balanced as indicated by their cholesterol and triglycerides levels.
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Objective: To assess the impact of implementation of the TeamSTEPPS teamwork improvement concept on patient safety culture. Design: Pre-post culture assessment using the Hospital Survey on Patient Safety Culture, at baseline and one year after implementation of TeamSTEPPS. Setting: Two maternity wards within the same 480-bed multisite teaching hospital. Intervention: Implementation of the TeamSTEPPS teamwork improvement concept. Main outcome measures: Analysis of variation of the percentage of positive responses (score) in both wards (intervention and control) was conducted. Results: There was a significant increase in scores in three dimensions of patient safety culture in the intervention ward: Supervisor/Manager Expectations and Actions Promoting Safety increased from 48.7% in 2015 to 70.8% in 2016 (P < 0.005); Teamwork Within Units increased from 35.5% in 2015 to 54.5% in 2016 (P < 0.005); Nonpunitive Response to Errors increased from 16.7% in 2015 to 32.3% in 2016 (P < 0.005). Other dimensions showed no significant changes. In the control ward, there was a significant decrease in scores in one dimension. A secondary analysis of differences in differences still shows significant improvement in one dimension (Supervisor/Manager Expectations and Actions Promoting Safety P < 0.005). Conclusion: After implementing the TeamSTEPPS teamwork concept, patient safety culture significantly improved for three of twelve dimensions in the intervention group. When controlling for differences in baseline scores between implementation and control wards, a significant improvement remains in one dimension. This suggests that TeamSTEPPS could be considered when seeking to enhance patient safety culture, especially in high-risk environments such as maternity wards.
Article
Background: Involuntary admission (IA) for psychiatric treatment has a history of controversial discussions. We aimed to describe characteristics of a cohort of involuntarily compared to voluntarily admitted patients regarding clinical and socio-demographic characteristics before and after implementation of the new legislation. Methods: In this observational cohort study, routine data of 15'125 patients who were admitted to the University Hospital of Psychiatry Zurich between 2008 and 2016 were analyzed using a series of generalized estimating equations. Results: At least one IA occurred in 4'560 patients (30.1%). Of the 31'508 admissions 8'843 (28.1%) were involuntary. In the final multivariable model, being a tourist (OR = 3.5) or an asylum seeker (OR = 2.3), having a schizophrenic disorder (OR = 2.1), or a bipolar disorder (OR = 1.8) contributed most to our model. Male gender, higher age, prescription of neuroleptics (all OR < 2.0) as well as having a depressive disorder, prescription of psychotherapy, prescription of antidepressants and admission after implementation of the new legislation (all OR > 0.6) were also weakly associated with IA. Conclusions: Besides schizophrenic or bipolar disorders, a small group of patients had an increased risk for IA due to non-clinical parameters (i.e. tourists and asylum seekers). Knowledge about risk factors should be used for the development of multi-level strategies to prevent frequent (involuntary) hospitalizations in patients at risk. On the organizational level, we could show that the new legislation decreased the risk for IA, and therefore may have succeeded in strengthening patient autonomy.
Article
Background: Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients. Methods: We did a stepped-wedge cluster-randomised trial of patients aged 40 years or older undergoing emergency open major abdominal surgery. Eligible UK National Health Service (NHS) hospitals (those that had an emergency general surgical service, a substantial volume of emergency abdominal surgery cases, and contributed data to the National Emergency Laparotomy Audit) were organised into 15 geographical clusters and commenced the QI programme in a random order, based on a computer-generated random sequence, over an 85-week period with one geographical cluster commencing the intervention every 5 weeks from the second to the 16th time period. Patients were masked to the study group, but it was not possible to mask hospital staff or investigators. The primary outcome measure was mortality within 90 days of surgery. Analyses were done on an intention-to-treat basis. This study is registered with the ISRCTN registry, number ISRCTN80682973. Findings: Treatment took place between March 3, 2014, and Oct 19, 2015. 22 754 patients were assessed for elegibility. Of 15 873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 patients in the usual care group and 7374 in the QI group. Eight patients in the usual care group and nine patients in the QI group were not included in the analysis because of missing primary outcome data. The primary outcome of 90-day mortality occurred in 1210 (16%) patients in the QI group compared with 1393 (16%) patients in the usual care group (HR 1·11, 0·96-1·28). Interpretation: No survival benefit was observed from this QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. Future QI programmes should ensure that teams have both the time and resources needed to improve patient care. Funding: National Institute for Health Research Health Services and Delivery Research Programme.
Article
Empirical research shows that medication safety is an urgent area of concern in the Swiss healthcare system. Adverse drug events and medication errors are common and risks such as polypharmacy are widespread. No comprehensive national strategy explicitly dedicated to medication safety exists in Switzerland. The federalist system of government with relative autonomy of the cantons relating to healthcare laws influences the implementation of national healthcare reforms, also to the disadvantage of medication safety. Direct dispensing of drugs by the prescribing physician is permitted in almost all German-speaking cantons. This special feature of the Swiss system implies specific challenges for medication safety. Nonetheless, there is an increasing number of national activities dealing with various aspects of medication safety, such as the "progress!" programmes within the National Quality Strategy. Within the National Research Programme "Smarter Health Care" (NRP 74) of the Swiss National Science Foundation, several research projects are currently focusing on medication safety. Clinical pharmacy activities in hospitals are relatively widespread. In the primary care sector, pharmaceutical care practice and the corresponding competencies for pharmacists are being further developed. However, a comprehensive strategy, priority-setting and effectiveness studies involving all stakeholders are required in order for the Swiss healthcare system, to meet the challenges facing medication safety in a forward-looking manner.