{"title":"Examining telehealth through the Institute of Medicine quality domains: unanswered questions and research agenda.","authors":"Timothy C Guetterman, Lorraine R Buis","doi":"10.1136/bmjqs-2023-016872","DOIUrl":"10.1136/bmjqs-2023-016872","url":null,"abstract":"","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":null,"pages":null},"PeriodicalIF":5.6,"publicationDate":"2024-08-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140897125","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Facundo Jorro-Baron, Cecilia Inés Loudet, Wanda Cornistein, Inés Suarez-Anzorena, Pilar Arias-Lopez, Carina Balasini, Laura Cabana, Eleonora Cunto, Pablo Rodrigo Jorge Corral, Luz Gibbons, Marina Guglielmino, Gabriela Izzo, Marianela Lescano, Claudia Meregalli, Cristina Orlandi, Fernando Perre, Maria Elena Ratto, Mariano Rivet, Ana Paula Rodriguez, Viviana Monica Rodriguez, Jacqueline Vilca Becerra, Paula Romina Villegas, Emilse Vitar, Javier Roberti, Ezequiel García-Elorrio, Viviana Rodriguez
{"title":"Optimising antibacterial utilisation in Argentine intensive care units: a quality improvement collaborative.","authors":"Facundo Jorro-Baron, Cecilia Inés Loudet, Wanda Cornistein, Inés Suarez-Anzorena, Pilar Arias-Lopez, Carina Balasini, Laura Cabana, Eleonora Cunto, Pablo Rodrigo Jorge Corral, Luz Gibbons, Marina Guglielmino, Gabriela Izzo, Marianela Lescano, Claudia Meregalli, Cristina Orlandi, Fernando Perre, Maria Elena Ratto, Mariano Rivet, Ana Paula Rodriguez, Viviana Monica Rodriguez, Jacqueline Vilca Becerra, Paula Romina Villegas, Emilse Vitar, Javier Roberti, Ezequiel García-Elorrio, Viviana Rodriguez","doi":"10.1136/bmjqs-2024-017069","DOIUrl":"https://doi.org/10.1136/bmjqs-2024-017069","url":null,"abstract":"<p><strong>Background: </strong>There is limited evidence from antimicrobial stewardship programmes in less-resourced settings. This study aimed to improve the quality of antibacterial prescriptions by mitigating overuse and promoting the use of narrow-spectrum agents in intensive care units (ICUs) in a middle-income country.</p><p><strong>Methods: </strong>We established a quality improvement collaborative (QIC) model involving nine Argentine ICUs over 11 months with a 16-week baseline period (BP) and a 32-week implementation period (IP). Our intervention package included audits and feedback on antibacterial use, facility-specific treatment guidelines, antibacterial timeouts, pharmacy-based interventions and education. The intervention was delivered in two learning sessions with three action periods along with coaching support and basic quality improvement training.</p><p><strong>Results: </strong>We included 912 patients, 357 in BP and 555 in IP. The latter had higher APACHE II (17 (95% CI: 12 to 21) vs 15 (95% CI: 11 to 20), p=0.036), SOFA scores (6 (95% CI: 4 to 9) vs 5 (95% CI: 3 to 8), p=0.006), renal failure (41.6% vs 33.1%, p=0.009), sepsis (36.1% vs 31.6%, p<0.001) and septic shock (40.0% vs 33.8%, p<0.001). The days of antibacterial therapy (DOT) were similar between the groups (change in the slope from BP to IP 28.1 (95% CI: -17.4 to 73.5), p=0.2405). There were no differences in the antibacterial defined daily dose (DDD) between the groups (change in the slope from BP to IP 43.9, (95% CI: -12.3 to 100.0), p=0.1413).The rate of antibacterial de-escalation based on microbiological culture was higher during the IP (62.0% vs 45.3%, p<0.001).The infection prevention control (IPC) assessment framework was increased in eight ICUs.</p><p><strong>Conclusion: </strong>Implementing an antimicrobial stewardship program in ICUs in a middle-income country via a QIC demonstrated success in improving antibacterial de-escalation based on microbiological culture results, but not on DOT or DDD. In addition, eight out of nine ICUs improved their IPC Assessment Framework Score.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":null,"pages":null},"PeriodicalIF":5.6,"publicationDate":"2024-08-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141987318","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Neetu Bansal, Christopher J Armitage, Rhiannon E Hawkes, Sarah Tinsley, Darren M Ashcroft, Li-Chia Chen
{"title":"Decoding behaviour change techniques in opioid deprescribing strategies following major surgery: a systematic review of interventions to reduce postoperative opioid use.","authors":"Neetu Bansal, Christopher J Armitage, Rhiannon E Hawkes, Sarah Tinsley, Darren M Ashcroft, Li-Chia Chen","doi":"10.1136/bmjqs-2024-017265","DOIUrl":"10.1136/bmjqs-2024-017265","url":null,"abstract":"<p><strong>Background and objectives: </strong>METHODS: A structured search strategy encompassing databases including MEDLINE, Embase, CINAHL Plus, PsycINFO and Cochrane Library was implemented from inception to October 2023. Included studies focused on interventions targeting opioid reduction in adults following major surgeries. The risk of bias was evaluated using Cochrane risk-of-bias tool V.2 (RoB 2) and non-randomised studies of interventions (ROBINS-I) tools, and Cohen's <i>d</i> effect sizes were calculated. BCTs were identified using a validated taxonomy.</p><p><strong>Results: </strong>22 studies, comprising 7 clinical trials and 15 cohort studies, were included, with varying risks of bias. Educational (n=12), guideline-focused (n=3), multifaceted (n=5) and pharmacist-led (n=2) interventions demonstrated diverse effect sizes (small-medium n=10, large n=12). A total of 23 unique BCTs were identified across studies, occurring 140 times. No significant association was observed between the number of BCTs and effect size, and interventions with large effect sizes predominantly targeted healthcare professionals. Key BCTs in interventions with the largest effect sizes included behaviour instructions, behaviour substitution, goal setting (outcome), social support (practical), social support (unspecified), pharmacological support, prompts/cues, feedback on behaviour, environmental modification, graded tasks, outcome goal review, health consequences information, action planning, social comparison, credible source, outcome feedback and social reward.</p><p><strong>Conclusions: </strong>Understanding the dominant BCTs in highly effective interventions provides valuable insights for future opioid tapering strategy implementations. Further research and validation are necessary to establish associations between BCTs and effectiveness, considering additional influencing factors.</p><p><strong>Prospero registration number: </strong>CRD42022290060.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":null,"pages":null},"PeriodicalIF":5.6,"publicationDate":"2024-08-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141791789","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Jacqui Prieto, Jennie Wilson, Alison Tingle, Emily Cooper, Melanie Handley, Jo Rycroft Malone, Jennifer Bostock, Heather Loveday
{"title":"Preventing urinary tract infection in older people living in care homes: the 'StOP UTI' realist synthesis.","authors":"Jacqui Prieto, Jennie Wilson, Alison Tingle, Emily Cooper, Melanie Handley, Jo Rycroft Malone, Jennifer Bostock, Heather Loveday","doi":"10.1136/bmjqs-2023-016967","DOIUrl":"https://doi.org/10.1136/bmjqs-2023-016967","url":null,"abstract":"<p><strong>Background: </strong>Urinary tract infection (UTI) is the most diagnosed infection in older people living in care homes.</p><p><strong>Objective: </strong>To identify interventions for recognising and preventing UTI in older people living in care homes in the UK and explain the mechanisms by which they work, for whom and under what circumstances.</p><p><strong>Methods: </strong>A realist synthesis of evidence was undertaken to develop programme theory underlying strategies to recognise and prevent UTI. A generic topic-based search of bibliographic databases was completed with further purposive searches to test and refine the programme theory in consultation with stakeholders.</p><p><strong>Results: </strong>56 articles were included in the review. Nine context-mechanism-outcome configurations were developed and arranged across three theory areas: (1) Strategies to support accurate recognition of UTI, (2) care strategies for residents to prevent UTI and (3) making best practice happen. Our programme theory explains how care staff can be enabled to recognise and prevent UTI when this is incorporated into care routines and activities that meet the fundamental care needs and preferences of residents. This is facilitated through active and visible leadership by care home managers and education that is contextualised to the work and role of care staff.</p><p><strong>Conclusions: </strong>Care home staff have a vital role in preventing and recognising UTI in care home residents.Incorporating this into the fundamental care they provide can help them to adopt a proactive approach to preventing infection and avoiding unnecessary antibiotic use. This requires a context of care with a culture of personalisation and safety, promoted by commissioners, regulators and providers, where leadership and resources are committed to support preventative action by knowledgeable care staff.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":null,"pages":null},"PeriodicalIF":5.6,"publicationDate":"2024-08-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141911647","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Tristan Price, Ellie Reynolds, Tim O'Brien, Thomas Gale, Oliver Quick, Marie Bryce
{"title":"Role of remediation in cases of serious misconduct before UK healthcare regulators: a qualitative study.","authors":"Tristan Price, Ellie Reynolds, Tim O'Brien, Thomas Gale, Oliver Quick, Marie Bryce","doi":"10.1136/bmjqs-2024-017187","DOIUrl":"https://doi.org/10.1136/bmjqs-2024-017187","url":null,"abstract":"<p><strong>Background: </strong>The raison d'etre of healthcare profession regulators across the globe is to protect patients and the public from the risk of harm. In cases of serious misconduct, remediation is deemed to be an important factor when considering the risk of harm from a practitioner under investigation. Yet, we know very little about how regulators account for remediation in their decision-making, and whether it is consistent with the aim of risk reduction. This paper explores the role of remediation in decision-making in cases of serious misconduct before UK healthcare regulators.</p><p><strong>Methods: </strong>We conducted interviews with 21 participants from across eight of the nine UK healthcare profession regulators, covering a range of roles in the decision-making process in misconduct cases. Interviews were conducted remotely by video call and digitally transcribed. Data were analysed using the framework analysis method. The initial framework was developed from existing literature and guidance documents from the regulators, and was subsequently refined through the various rounds of coding.</p><p><strong>Results: </strong>Remediation influenced decision-making in three ways: (1) Some types of misconduct were deemed more inherently remediable than others. In cases involving dishonesty or sexual misconduct, remediation was less likely to serve as a mitigating factor. (2) Decision-makers often view remediation as a proxy indicator of practitioner insight. (3) Whether a practitioner had demonstrated their commitment to change through undergoing remediation was more likely to feed into decision-making at the point where current impairment was under consideration.</p><p><strong>Conclusions: </strong>Remediation plays a key role in decision-makers' judgements in cases of misconduct, particularly when these cases relate to clinical misconduct. In such cases, remediation informs judgements on the levels of practitioner insight and the risk of such misconduct being repeated. Our results suggest a need to develop remediation interventions that are explicitly geared towards the regulatory function of developing practitioner insight. Regulators should also consider the structure of their fitness to practise processes and whether there are appropriate opportunities for judgements on remediation to feed into decisions and to facilitate balanced and proportionate outcomes.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":null,"pages":null},"PeriodicalIF":5.6,"publicationDate":"2024-08-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141896743","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Sarah Hampton, Jenni Murray, Rebecca Lawton, Laura Sheard
{"title":"Understanding the challenges and successes of implementing 'hybrid' interventions in healthcare settings: findings from a process evaluation of a patient involvement trial.","authors":"Sarah Hampton, Jenni Murray, Rebecca Lawton, Laura Sheard","doi":"10.1136/bmjqs-2024-017268","DOIUrl":"https://doi.org/10.1136/bmjqs-2024-017268","url":null,"abstract":"<p><strong>Introduction: </strong>'Hybrid' interventions in which some intervention components are fixed across sites and others are flexible (locally created) are thought to allow for adaptation to the local context while maintaining fidelity. However, there is little evidence regarding the challenges and facilitators of implementing hybrid interventions. This paper reports on a process evaluation of a patient safety hybrid intervention called Your Care Needs You (YCNY). YCNY was tested in the Partners at Care Transitions (PACT) randomised controlled trial and aimed to enhance older patients and their families' involvement in their care in order to achieve safer transitions from hospital to home.</p><p><strong>Methods: </strong>The process evaluation took place across eight intervention wards taking part in the PACT trial. 23 interviews and 37 informal conversations were conducted with National Health Service (NHS) staff. Patients (n=19) were interviewed twice, once in hospital and once after discharge. Interviews with staff and patients concerned the delivery and experiences of YCNY. Ethnographic observations (n=81 hours) of relevant activities (eg, multidisciplinary team meetings, handovers, etc) were undertaken.</p><p><strong>Results: </strong>The main finding relates to how staff understood and engaged with YCNY, which then had a major influence on its implementation. While staff broadly valued the aims of YCNY, staff from seven out of the eight wards taking part in the process evaluation enacted YCNY in a mostly task-based manner. YCNY implementation often became a hurried activity which concentrated on delivering fixed intervention components rather than a catalyst for culture change around patient involvement. Factors such as understaffing, constraints on staff time and the COVID-19 pandemic contributed towards a 'taskification' of intervention delivery, which meant staff often did not have capacity to creatively devise flexible intervention components. However, one ward with a sense of distributed ownership of YCNY had considerable success implementing flexible components.</p><p><strong>Discussion: </strong>Hybrid interventions may allow aspects of an intervention to be adapted to the local context. However, the current constrained and pressured environment of the NHS left staff with little ability to creatively engage with devising flexible intervention components, despite recognising the need for and being motivated to deliver the intervention.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":null,"pages":null},"PeriodicalIF":5.6,"publicationDate":"2024-08-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141896744","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Meagan M Ladell, Sarah Yale, Brett J Bordini, Matthew C Scanlon, Nancy Jacobson, Elizabeth Lerner Papautsky
{"title":"Why a sociotechnical framework is necessary to address diagnostic error.","authors":"Meagan M Ladell, Sarah Yale, Brett J Bordini, Matthew C Scanlon, Nancy Jacobson, Elizabeth Lerner Papautsky","doi":"10.1136/bmjqs-2024-017231","DOIUrl":"https://doi.org/10.1136/bmjqs-2024-017231","url":null,"abstract":"","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":null,"pages":null},"PeriodicalIF":5.6,"publicationDate":"2024-08-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141888426","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Kristin Hestmann Vinjerui, Andreas Asheim, Kjartan Sarheim Anthun, Fredrik Carlsen, Bente Prytz Mjølstad, Sara Marie Nilsen, Kristine Pape, Johan Håkon Bjørngaard
{"title":"General practitioners retiring or relocating and its association with healthcare use and mortality: a cohort study using Norwegian national data.","authors":"Kristin Hestmann Vinjerui, Andreas Asheim, Kjartan Sarheim Anthun, Fredrik Carlsen, Bente Prytz Mjølstad, Sara Marie Nilsen, Kristine Pape, Johan Håkon Bjørngaard","doi":"10.1136/bmjqs-2023-017064","DOIUrl":"https://doi.org/10.1136/bmjqs-2023-017064","url":null,"abstract":"<p><strong>Background: </strong>Continuity in the general practitioner (GP)-patient relationship is associated with better healthcare outcomes. However, few studies have examined the impact of permanent discontinuities on all listed patients when a GP retires or relocates.</p><p><strong>Aim: </strong>To investigate changes in the Norwegian population's overall healthcare use and mortality after discontinuity due to Regular GPs retiring or relocating.</p><p><strong>Methods: </strong>Linking national registers, we compared days with healthcare use and mortality for matched individuals affiliated with Regular GPs who retired or relocated versus continued. We included list patients 3 years prior to exposure and followed them up to 5 years after. We assessed changes over time employing a difference-in-differences design with Poisson regression.</p><p><strong>Results: </strong>From 2011 to 2020, we identified 819 Regular GPs retiring and 228 moving, affiliated with 1 165 295 people. Relative to 3 years before discontinuity, the rate ratio (RR) of daytime GP contacts, increased 3% (95% CI 2 to 4) in year 1 after discontinuity, corresponding to 148 (95% CI 54 to 243) additional contacts per 1000 patients. This increase persisted for 5 years. Out-of-hours GP contacts increased the first year, RR 1.04 (95% CI 0.99 to 1.09), corresponding to 16 (95% CI -5 to 37) contacts per 1000 patients. Planned hospital contacts increased 3% (95% CI 2 to 4) in year 1, persisting into year 5. Acute hospital contacts increased 5% (95% CI 3 to 7), primarily in the first year. These 1-year effects corresponded to 51 (95% CI 18 to 83) planned and 13 (95% CI 7 to 18) acute hospital contacts per 1000 patients. Mortality was unchanged up to 5 years after discontinuity.</p><p><strong>Conclusion: </strong>Regular GPs retirement and relocation were associated with small to moderate increases in healthcare use among listed patients, while mortality was unaffected.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":null,"pages":null},"PeriodicalIF":5.6,"publicationDate":"2024-07-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141765407","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"An anthropologist’s insight into healthcare data – multiple and rich of contradictions","authors":"Valentina Lichtner","doi":"10.1136/bmjqs-2024-017687","DOIUrl":"https://doi.org/10.1136/bmjqs-2024-017687","url":null,"abstract":"Readers of this journal will be familiar with the power of data to inform healthcare decisions, processes, policies and investments, with the goal of better patient care. They may also know first-hand how these data are always limited, partial, political and context-dependent,1–3 yet useful and necessary nonetheless. This is one of the data paradoxes recounted in the book by the same name,4 by Professor Klaus Hoeyer, University of Copenhagen. The book examines the work that is required to produce and use data in healthcare, while also exploring the contradictions inherent in these data that make it challenging to inform improvements, practice and policy. It is based on research about the Danish healthcare system, although its arguments are applicable internationally. The paradoxes are universal, as is the data work involved. The book is rich in conceptual insight, anecdotes and storytelling and questions our data knowledge, judgement and wisdom. This is the type of insight one gets from anthropology5—and its core method, ethnography6—which can challenge assumptions and reveal the lived experience and complexity of health and healthcare. In the quality improvement community, insight from anthropology and ethnography is sought to identify aspects of care that need improvement,6 as well as ‘what good looks like’,7 while being aware …","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":null,"pages":null},"PeriodicalIF":5.4,"publicationDate":"2024-07-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141778120","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}