Measurement for improvement: a survey of current practice in Australian public hospitals

Objective:
To identify patient safety measurement tools in use in Australian public hospitals and to determine barriers to their use.

Design:
Structured survey, conducted between 4 March and 19 May 2005, designed to identify tools, and to assess current use of, levels of satisfaction with, and barriers to use of tools for measuring the domains and subdomains of: organisational capacity to provide safe health care; patient safety incidents; and clinical performance.

Participants and setting:
Hospital executives, managers and clinicians from a nationwide random sample of Australian public hospitals stratified by state and hospital peer grouping.

Main outcome measures:
Tools used by hospitals within the three domains and their subdomains; patient safety tools and processes identified by individuals at these hospitals; satisfaction with the tools; and barriers to their use.

Results:
Eighty-two of 167 invited hospitals (49%) responded. The survey ascertained a comprehensive list of patient safety measurement tools that are in current use for measuring all patient safety domains. Overall, there was a focus on use of processes rather than quantitative measurement tools. Approximately half the 182 individual respondents from participating hospitals reported satisfaction with existing tools. The main reported barriers were lack of integrated supportive systems, resource constraints and inadequate access to robust measurement tools validated in the Australian context. Measurement of organisational capacity was reported by 50 (61%), of patient safety incidents by 81 (99%) and of clinical performance by 81 (99%).

Conclusion:
Australian public hospitals are measuring the safety of their health care, with some variation in measurement of patient safety domains and their subdomains. Improved access to robust tools may support future standardisation of measurement for improvement.

The complexity of social practice : understanding inertia and change in maternity care organizations

Beyond the limited efficiency and economy goals of neoliberal health policy lies the promise of genuine health services reform. In maternity care in particular, recent policy developments have sought to make the management of birth more ‘women-centred and family-friendly’. Interprofessional collaboration and greater consumer participation in policy and decision-making are key means to achieve this goal, but changing the entrenched system of medicalised birth remains difficult. Recent social contestation of maternity care has destabilised but not eradicated pervasive medical hegemony. Further reform requires analysis both of institutionalised patterns of power, and attention to the fluidity and situated knowledge shaping organisational and professional practices. Accordingly, this paper outlines a framework with which to explore the multi-layered social processes involved in implementing organisational and cultural change in maternity care. Analysis of social interventions in health systems, we suggest, can be advanced by drawing on strands from critical organization studies, complexity and critical discourse theories and social practice approaches.

Barriers to care for depressed older people : perceptions of aged care among medical professionals

The current study evaluated barriers to detection of depression among older people. Focus groups were conducted with 21 professional carers, 4 nurses, 10 general practitioners, and 7 aged care managers. The results demonstrated that care for older people is primarily focused on physical care. Further, staff resources, a lack of continuity of care, multiple co-morbidities, reluctance by older people to discuss depression, negative attitudes among carers, as well as a lack of skills all contributed to a failure to detect and treat depression. The implications of these findings for training programs for professional carers are discussed.

What's wrong with me? Concerns about online medical self-diagnosis

Self-service technologies (SSTs) are becoming increasingly commonplace in healthcare. However, research on the customer (patient) experience in this context is rare. This paper focuses on online medical self-diagnosis, a type of e-health service. This SST can provide customers with benefits such as greater convenience and control, yet we argue that this form of do-it-yourself doctoring also raises concerns for customers. This paper contributes to the service domain by presenting research propositions on the potential negative implications for customers, and their antecedents, of online medical self-diagnosis. We propose that this form of self-diagnosis is related to harms, such as customer anxiety, customer willingness to bypass healthcare professionals, and self-medication. Future research opportunities are discussed, along with implications for policy and practice.

Developing Clinical Practice Guidelines for violence risk assessment in mental health triage : a systematic review

Background : On a global level, there is a growing trend to utilise mental health triage service systems as a way of providing consumers with access to 24 hour mental health care. At present, violence risk assessment in mental health triage lacks a suitable evidence base and clear guidelines. This presentation provides an overview of a Clinical Practice Guideline for violence risk assessment at point of entry to health services.
Aims : The objective of this study was to develop Clinical Practice Guidelines for violence risk assessment in mental health triage, and to pilot test the Clinical Guidelines in two major hospitals in Melbourne.
Method : The method employed in the study was a systematic review, as per the Australian National Health and Medical Research Council’s methodology for developing Clinical Guidelines. Research was conducted at the Royal Melbourne Hospital and the Alfred Hospital to establish the utility of the Guideline in practice.
Results : The systematic review established the highest level of evidence for violence risk assessment. Clinical Practice Guidelines for mental health triage were developed from these findings.
Conclusions : Evidence based Clinical Guidelines maximise the potential for creating safer outcomes for consumers, families/carers, and health care workers.

Putting woman-centered care into practice : a new (ANEW) approach to psychosocial risk assessment during pregnancy

Background: When antenatal care is provided, identification and management of challenging problems, such as depression, domestic violence, child abuse, and substance abuse, are absent from traditional midwifery and medical training. The main objective of this project was to provide an alternative to psychosocial risk screening in pregnancy by offering a training program (ANEW) in advanced communication skills and common psychosocial issues to midwives and doctors, with the aim of improving identification and support of women with psychosocial issues in pregnancy.

Methods: ANEW used a before‐and‐after survey design to evaluate the effects of a 6‐month educational intervention for health professionals. The setting for the project was the Mercy Hospital for Women in Melbourne, Australia. Surveys covered issues, such as perceived competency and comfort in dealing with specific psychosocial issues, self‐rated communication skills, and open‐ended questions about participants' experience of the educational program.

Results: Educational program participants (n = 22/27) completed both surveys. After the educational intervention, participants were more likely to ask directly about domestic violence (p = 0.05), past sexual abuse (p = 0.05), and concerns about caring for the baby (p = 0.03). They were less likely to report that psychosocial issues made them feel overwhelmed (p = 0.01), and they reported significant gains in knowledge of psychosocial issues, and competence in dealing with them. Participants were highly positive about the experience of participating in the program.

Conclusions:The program increased the self‐reported comfort and competency of health professionals to identify and care for women with psychosocial issues.

Nurses' perceived barriers to the implementation of a Fall Prevention Clinical Practice Guideline in Singapore hospitals

Background

Theories of behavior change indicate that an analysis of barriers to change is helpful when trying to influence professional practice. The aim of this study was to assess the perceived barriers to practice change by eliciting nurses' opinions with regard to barriers to, and facilitators of, implementation of a Fall Prevention clinical practice guideline in five acute care hospitals in Singapore.
Methods

Nurses were surveyed to identify their perceptions regarding barriers to implementation of clinical practice guidelines in their practice setting. The validated questionnaire, 'Barriers and facilitators assessment instrument', was administered to nurses (n = 1830) working in the medical, surgical, geriatric units, at five acute care hospitals in Singapore.
Results

An 80.2% response rate was achieved. The greatest barriers to implementation of clinical practice guidelines reported included: knowledge and motivation, availability of support staff, access to facilities, health status of patients, and, education of staff and patients.
Conclusion

Numerous barriers to the use of the Fall Prevention Clinical Practice Guideline have been identified. This study has laid the foundation for further research into implementation of clinical practice guidelines in Singapore by identifying barriers to change in acute care settings.

Implementation of clinical practice guidelines using simulation in education

Background: Underpinning the Department of Human Services (DHS) “Future directions for Victoria’s maternity services” strategy in Victoria, are the principles of achieving the right balance between primary level care and access to appropriate levels of medical care by making the best use of the complementary skills of midwives, GPs and obstetricians. Planning new models of care have exposed a need to upskill many clinicians in providing evidence based pregnancy care. A statewide education program conducts 1 day workshops to multidisciplinary forums in Victoria. The program content is developed with each service and simulation activities are incorporated in the workshop to provide a realistic environment for practising skills related to the implementation of clinical practice guidelines.

Method: Post workshop surveys are completed anonymously by participants using a five point Likert scale to evaluate their experiences in peer learning, the use of simulation, reflective practice and communication skills training. Open ended responses were analysed thematically.

Results: In 2007, 14 workshops were conducted with 254 clinicians attending. The survey response rate was 80%. Participants responded ‘strongly agree’ or ‘agree’ that the workshop: enhanced their ability to access current pregnancy care research and information 193/ 204(95%), challenged them to think more broadly 192/204(94%), provided an opportunity to reflect on their communication skills during the simulation actives 197/201 (96%) and provided a valuable opportunity for observing the communication skills of their peers 197/ 201(98%).

Conclusion: Providing opportunities for peer learning in pregnancy education is valuable and the use of simulation can play an important role in overcoming barriers to implementing guidelines.

Medical error and decision making : learning from the past and present in intensive care

Background : Human error occurs in every occupation. Medical errors may result in a near miss or an actual injury to a patient that has nothing to do with the underlying medical condition. Intensive care has one of the highest incidences of medical error and patient injury in any specialty medical area; thought to be related to the rapidly changing patient status and complex diagnoses and treatments.

Purpose : The aims of this paper are to: (1) outline the definition, classifications and aetiology of medical error; (2) summarise key findings from the literature with a specific focus on errors arising from intensive care areas; and (3) conclude with an outline of approaches for analysing clinical information to determine adverse events and inform practice change in intensive care.

Data source : Database searches of articles and textbooks using keywords: medical error, patient safety, decision making and intensive care. Sociology and psychology literature cited therein.

Findings : Critically ill patients require numerous medications, multiple infusions and procedures. Although medical errors are often detected by clinicians at the bedside, organisational processes and systems may contribute to the problem. A systems approach is thought to provide greater insight into the contributory factors and potential solutions to avoid preventable adverse events.

Conclusion : It is recommended that a variety of clinical information and research techniques are used as a priority to prevent hospital acquired injuries and address patient safety concerns in intensive care.

The delivery of a telephone coaching programme to people with type 2 diabetes by practice nurses in Victoria, Australia : a qualitative evaluation

Aim.  To evaluate telephone coaching undertaken by practice nurses in a randomised controlled trial of self-management support for people with type 2 diabetes.

Background.  Qualitative evaluation of the processes that take place in randomised controlled trials has the advantage of providing information on those variables that contribute to the success or failure of the randomised controlled trial. This additional information can be used to improve or modify chronic disease management programme designs.

Methods.  Grounded theory was used to analyse transcriptions of telephone coaching sessions between practice nurses and patient participants in the randomised controlled trial.

Findings.   Analysis of transcriptions found that patient participants had complex multiple medical conditions to manage, as well as maintaining their daily lives. Two approaches to working with this complexity by practice nurses emerged. We characterised one as ‘treat to target’ and the other as ‘personalised care’. While each approach shapes identities available to patients within the relationship with the practice nurse, the impact or effectiveness of these approaches on outcomes has yet to be reported.

Conclusions.  Telephone coaching takes place in complex social contexts as well as complex medical conditions. People with type 2 diabetes must manage their diabetes care and their care of other conditions within their social contexts. This means a constant negotiation of priorities.

Relevance to clinical practice.  Awareness of how health professional support for patients’ self-management becomes a relationship and element of the negotiated identity of patients is important in adapting clinical guideline-based protocols to achieving targets in the management of chronic illness.

How is the diagnosis of asthma in older people established in clinical practice?

What we need to know
• How is breathlessness perceived and defined in older people?
• What impact does breathlessness have on quality of life?
• Can history taking and physical examination be tailored to efficiently cover all the organ systems associated with
breathlessness?
• Can a self- or carer-rated questionnaire be used to identify asthma in patients with breathlessness?
What we need to do
• Develop self- and carer-rated questionnaires that measure change in function and quality of life before and after
treatment.
• Validate objective measures of physical function and airflow that are sufficiently sensitive to measure change with
treatment.
• Develop a diagnostic guideline in general practice that includes measures of mood and cognitive function and
involves carers where necessary.
• Provide rehabilitation and restorative care services.

Assessment of variation in the alberta context tool : the contribution of unit level contextual factors and practice specialty in Canadian pediatric acute care settings

Background: There are few validated measures of organizational context and none that we located are parsimonious and address modifiable characteristics of context. The Alberta Context Tool (ACT) was developed to meet this need. The instrument assesses 8 dimensions of context, which comprise 10 concepts. The purpose of this paper is to report evidence to further the validity argument for ACT. The specific objectives of this paper are to: (1) examine the extent to which the 10 ACT concepts discriminate between patient care units and (2) identify variables that significantly contribute to between-unit variation for each of the 10 concepts.

Methods: 859 professional nurses (844 valid responses) working in medical, surgical and critical care units of 8 Canadian pediatric hospitals completed the ACT. A random intercept, fixed effects hierarchical linear modeling (HLM) strategy was used to quantify and explain variance in the 10 ACT concepts to establish the ACT’s ability to discriminate between units. We ran 40 models (a series of 4 models for each of the 10 concepts) in which we systematically assessed the unique contribution (i.e., error variance reduction) of different variables to between-unit variation. First, we constructed a null model in which we quantified the variance overall, in each of the concepts. Then we controlled for the contribution of individual level variables (Model 1). In Model 2, we assessed the contribution of practice specialty (medical, surgical, critical care) to variation since it was central to construction of the sampling frame for the study. Finally, we assessed the contribution of additional unit level variables (Model 3).

Results: The null model (unadjusted baseline HLM model) established that there was significant variation between units in each of the 10 ACT concepts (i.e., discrimination between units). When we controlled for individual characteristics, significant variation in the 10 concepts remained. Assessment of the contribution of specialty to between-unit variation enabled us to explain more variance (1.19% to 16.73%) in 6 of the 10 ACT concepts. Finally, when we assessed the unique contribution of the unit level variables available to us, we were able to explain additional variance (15.91% to 73.25%) in 7 of the 10 ACT concepts.

Conclusion: The findings reported here represent the third published argument for validity of the ACT and adds to the evidence supporting its use to discriminate patient care units by all 10 contextual factors. We found evidence of relationships between a variety of individual and unit-level variables that explained much of this between-unit variation for each of the 10 ACT concepts. Future research will include examination of the relationships between the ACT’s contextual factors and research utilization by nurses and ultimately the relationships between context, research utilization, and outcomes for patients.

Multifactorial influences on and deviations from medication administration safety and quality in the acute medical/surgical context

Background and Aims: Although numerous factors influence medication administration, our understanding of the interplay of these factors on medication quality and safety is limited. The aim of this study was to explore the multifactorial influences on medication quality and safety in the context of a single checking policy for medication administration in acute care.

Approach: An exploratory/descriptive study using non-participant observation and follow-up interview was used to identify factors influencing medication quality and safety in medication administration episodes (n = 30). Observations focused on nurses’ interactions with patients during medication administration, and the characteristics of the environment in which these took place. Confirmation of observed data occurred on completion of the observation period during short semi-structured interviews with participant nurses.

Findings: Findings showed nurses developed therapeutic relationships with patients in terms of assessing patients before administering medications and educating patients about drugs during medication administration. Nurses experienced more frequent distractions when medications were stored and prepared in a communal drug room according to ward design. Nurses deviated from best-practice guidelines during medication administration.

Implications: Nurses’ abilities and readiness to develop therapeutic relationships with patients increased medication quality and safety, thereby protecting patients from potential adverse events. Deviations from best-practice medication administration had the potential to decrease medication safety. System factors such as ward design determining medication storage areas can be readily addressed to minimise potential error.

Conclusions: Nurses displayed behaviours that increased medication administration quality and safety; however, violations of practice standards were observed. These findings will inform future intervention studies to improve medication quality and safety.