BMJ quality improvement reports最新文献

{"title":"The Value of a Surgical Assessment Unit Ultrasound Facility.","authors":"Wesley Lai,&nbsp;Catherine Gutteridge,&nbsp;Alicia Regan,&nbsp;Anthony Lambert","doi":"10.1136/bmjquality.u209155.w3729","DOIUrl":"https://doi.org/10.1136/bmjquality.u209155.w3729","url":null,"abstract":"<p><p>Ultrasound scan (USS) is a common and important mode of investigation for emergency surgical admissions. Delay in investigation often leads to delayed diagnosis and treatment, and possible extended length of stay (LOS), which has clinical, cost and service provision implications. We aim to investigate the clinical impact on patient care and the cost-effectiveness of a pilot Surgical Assessment Unit (SAU) USS facility. We performed a retrospective data collection on 100 consecutive SAU inpatients who had an USS investigation on the ward since the introduction of the facility, matched by 100 consecutive SAU inpatients who had an USS in the radiology department before the pilot study. Results of the audit show SAU USS has a reduced mean LOS by 1.44 days compared to departmental USS, and led to more same day discharge than departmental USS (20 vs. 5), thus avoiding unnecessary overnight stay. It also significantly reduced mean waiting time from admission to investigation by 5.21 hours, which can be translated into improved patient and staff satisfaction. All these findings are both statistically and clinically significant. The estimated cost of each SAU USS is comparable to the average departmental USS (£29.71 vs. £30.80). Using the average cost of an excess bed day = £273, SAU USS has produced an estimated saving of £394.72/patient. This does not include saved opportunistic costs such as prevented elective operation cancellations, fines incurred from surgery waiting time/A+E breaches etc. To conclude SAU USS has a significant positive impact on patient care in surgical admissions by reducing LOS and investigation waiting time, as well as facilitating same day discharge.</p>","PeriodicalId":91218,"journal":{"name":"BMJ quality improvement reports","volume":"6 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2017-04-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjquality.u209155.w3729","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"34966407","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"SWITCH: Al Wakra Hospital Journey to 90% Hand Hygiene Practice Compliance, 2011 - 2015.","authors":"Feah Altura- Visan, Almunzer Zakaria, Jenalyn Castro, Omar Alhasanat, Khalil Al Ismail, Naser Al Ansari, Manal Hamed","doi":"10.1136/bmjquality.u211699.w4824","DOIUrl":"10.1136/bmjquality.u211699.w4824","url":null,"abstract":"<p><p>Hand Hygiene is the cheapest and simplest way to prevent the spread of infection, however international compliance is below than 40% (WHO, 2009). In the experience of Al Wakra Hospital, the improvement in hand hygiene compliance highlighted not just interventions towards training and education but also behavioral motivation and physical allocations of hand hygiene appliances and equipment. Through motivating the behavioral, emotional, physical and intellectual dimensions of the different healthcare worker professions, hand hygiene compliance has increased from 60.78% in 2011 to 94.14% by the end of December 2015. It took 25 months of continuous and collaborative work with different healthcare workers to reach the 90% hand hygiene target. \"Together, we have reached our goals and together we fight against infections! Because we always strive for excellence in everything we do - that is our vision here in Al Wakra Hospital.\"</p>","PeriodicalId":91218,"journal":{"name":"BMJ quality improvement reports","volume":"6 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2017-04-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/f0/98/bmjqir.u211699.w4824.PMC5411721.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"34965391","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Reducing returns to theatre for neck of femur fracture patients.","authors":"Selina Graham,&nbsp;Mark Dahill,&nbsp;Derek Robinson","doi":"10.1136/bmjquality.u215756.w6261","DOIUrl":"https://doi.org/10.1136/bmjquality.u215756.w6261","url":null,"abstract":"<p><p>The Royal United Hospital, Bath, admits approximately 550 patients with neck of femur fractures per year. The risks from returning to theatre for this patient group are often life-threatening. Post-operative wound ooze was noted to cause a significant rate of return to theatre, with increased lengths of stay and patient morbidity. A wound closure protocol was agreed by the consultant body. This information was disseminated by email and teaching sessions to all members of the multidisciplinary team, including surgeons, theatre staff and ortho-geriatricians. The plan-do-study-act model for improvement was used to reduce rates of returns to theatre for wound ooze. Interventions included cyclical teaching during each trainee rotation, updated inductions, posters, email reminders and scrub team involvement to open the protocol sutures unprompted. The primary outcome measure was returns to theatre for wound complications. Baseline data showed 4 returns to theatre over a two month period (4.40% of patients). Length of stay for each patient affected by wound ooze was also compared to the departmental mean. In the 6 month intervention period there was one return to theatre (0.36% of patients). The observed reduction saved the department an estimated £13,831 in length of stay alone. The standardisation of wound closure protocol, with continued reinforcement to all members of the multidisciplinary team, improves patient outcome in this group. Mobilising a group of clinicians across a variety of specialities, with one common goal, is highly effective for patients, improves multidisciplinary working and reduces cost.</p>","PeriodicalId":91218,"journal":{"name":"BMJ quality improvement reports","volume":"6 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2017-04-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjquality.u215756.w6261","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"34965388","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Transitional care management in the outpatient setting.","authors":"Analiza Baldonado,&nbsp;Ofelia Hawk,&nbsp;Thomas Ormiston,&nbsp;Danielle Nelson","doi":"10.1136/bmjquality.u212974.w5206","DOIUrl":"https://doi.org/10.1136/bmjquality.u212974.w5206","url":null,"abstract":"<p><p>Patients who are high risk high cost (HRHC), those with severe or multiple medical issues, and the chronically ill elderly are major drivers of rising health care costs.1 The HRHC patients with complex health conditions and functional limitations may likely go to emergency rooms and hospitals, need more supportive services, and use long-term care facilities.2 As a result, these patient populations are vulnerable to fragmented care and \"falling through the cracks\".2 A large county health and hospital system in California, USA introduced evidence-based interventions in accordance with the Triple AIM3 focused on patient-centered health care, prevention, health maintenance, and safe transitions across the care continuum. The pilot program embedded a Transitional Care Manager (TCM) within an outpatient Family Medicine clinic to proactively assist HRHC patients with outreach assistance, problem-solving and facilitating smooth transitions of care. This initiative is supported by a collaborative team that included physicians, nurses, specialists, health educator, and pharmacist. The initial 50 patients showed a decrease in Emergency Department (ED) encounters (pre-vs post intervention: 33 vs 17) and hospital admissions (pre-vs post intervention: 32 vs 11), improved patient outcomes, and cost saving. As an example, one patient had 1 ED visit and 5 hospital admission with total charges of $217,355.75 in the 6 months' pre-intervention with no recurrence of ED or hospital admissions in the 6 months of TCM enrollment. The preliminary findings showed improvement of patient-centered outcomes, quality of care, and resource utilization however more data is required.</p>","PeriodicalId":91218,"journal":{"name":"BMJ quality improvement reports","volume":"6 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2017-04-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjquality.u212974.w5206","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"34965389","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Gout in primary care: Can we improve patient outcomes?","authors":"Jacqueline Callear,&nbsp;Georgina Blakey,&nbsp;Alexandra Callear,&nbsp;Linda Sloan","doi":"10.1136/bmjquality.u210130.w4918","DOIUrl":"https://doi.org/10.1136/bmjquality.u210130.w4918","url":null,"abstract":"<p><p>In the United Kingdom, gout represents one of the most common inflammatory arthropathies predominantly managed in the primary care setting. Gout is a red flag indicator for cardiovascular disease and comorbidity. Despite this, there are no incentivised treatment protocols and suboptimal management in the primary care setting is common. A computer based retrospective search at a large inner city GP practice between January 2014-December 2014 inclusive, identified 115 patients with gout. Baseline measurements revealed multiple gout related consultations, poor medication compliance, high uric acid levels and deficiencies in uric acid monitoring. A series of improvement cycles were conducted. A telephone questionnaire conducted in January 2015, identified that patient education was suboptimal. The following improvement cycles aimed to educate patients, improve uric acid monitoring and support medication compliance. It was ultimately hoped that these measures would reduce gout flares and GP practice attendance. The improvement cycles contributed towards reduction in uric acid levels from 0.37 to 0.3 (p=0.14), 20% reduction in patients experiencing one or more gout flares and 77% reduction in GP related consultations between March 2015-March 2016 compared to baseline. The proportion of patients fully compliant with taking their urate lowering therapies improved from 63% to 91% (p=0.0001). A follow up series of PDSA cycles were performed between July-December 2016. The purpose of these cycles was to assess the sustainability of the improved medication compliance demonstrated by the improvement cycles. Three months following the completion of the improvement cycles, full medication compliance dropped from 91% to 70% (p=0.0001). The introduction of a paper calendar saw sustained and maintained improvement in medication compliance to 100% (p=0.0001) at the end of the study period. The improvement and PDSA cycles have demonstrated that simple interventions can be a sustainable way of improving disease control and patient outcomes.</p>","PeriodicalId":91218,"journal":{"name":"BMJ quality improvement reports","volume":"6 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2017-04-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjquality.u210130.w4918","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"34965395","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A Unified Electronic Tool for CPR and Emergency Treatment Escalation Plans Improves Communication and Early Collaborative Decision Making for Acute Hospital Admissions.","authors":"Mae Johnson,&nbsp;Martin Whyte,&nbsp;Robert Loveridge,&nbsp;Richard Yorke,&nbsp;Shairana Naleem","doi":"10.1136/bmjquality.u213254.w6626","DOIUrl":"https://doi.org/10.1136/bmjquality.u213254.w6626","url":null,"abstract":"<p><p>The National Confidential Enquiry into Patient Outcomes and Death (NCEPOD) report 'Time to Intervene' (2012) stated that in a substantial number of cases, resuscitation is attempted when it was thought a 'do not attempt cardiopulmonary resuscitation' (DNACPR) decision should have been in place. Early decisions about CPR status and advance planning about limits of care now form part of national recommendations by the UK Resuscitation Council (2016). Treatment escalation plans (TEP) document what level of treatment intervention would be appropriate if a patient were to become acutely unwell and were not previously formally in place at King's College Hospital. A unifying paper based form was successfully piloted in the Acute Medical Unit, introducing the TEP and bringing together decision making around both treatment escalation and CPR status. Subsequently an electronic order-set for CPR status and treatment escalation was launched in April 2015 which led to a highly visible CPR and escalation status banner on the main screen at the top of the patient's electronic record. Ultimately due to further iterations in the electronic process by December 2016, all escalation decisions for acutely admitted patients now have high quality supporting, explanatory documentation with 100% having TEPs in place. There is now widespread multidisciplinary engagement in the process of defining limits of care for acutely admitted medical patients within the first 14 hours of admission and a strategy for rolling this process out across all the divisions of the hospital through our Deteriorating Patient Group (DPG). The collaborative design with acute medical, palliative and intensive care teams and the high visibility provided by the electronic process in the Electronic Patient Record (EPR) has enhanced communication with these teams, patients, nursing staff and the multidisciplinary team by ensuring clarity through a universally understood process about escalation and CPR. Clarity and openness about these discussions have been welcomed by patient focus groups facilitated via our acute medicine patient experience committee. There has been a shift in medical culture where transparency about limits of care has contributed to improving patient safety and quality of care through reducing unnecessary CPR supported by focus groups of staff.</p>","PeriodicalId":91218,"journal":{"name":"BMJ quality improvement reports","volume":"6 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2017-04-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjquality.u213254.w6626","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"34966409","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A Quality Improvement Approach to Standardization and Sustainability of the Hand-off Process.","authors":"Craig Fryman, Carine Hamo, Siddharth Raghavan, Nirvani Goolsarran","doi":"10.1136/bmjquality.u222156.w8291","DOIUrl":"10.1136/bmjquality.u222156.w8291","url":null,"abstract":"<p><p>There is mounting evidence that communication and hand-off failures are a root cause of two-thirds of sentinel events in hospitals. Several studies have shown that non-standardized hand-offs have yielded poor patient outcomes and adverse events. At Stony Brook University Hospital, there were numerous reported adverse events related to poor hand-off during the transfer of patient responsibility from one resident caregiver to the next. A resident-conducted root cause analysis identified lack of a standardized hand-off process and formal training on safe and efficient hand-off among caregivers as key contributing factors. This quality improvement project used the PDSA methodology to test the use of a standardized method, the IPASS mnemonic, and compare it to our conventional hand-off method in our internal medicine residency program. The main goals of this study were to test the feasibility and effectiveness of a standardized I- PASS hand-off and to create a robust sustainability model that includes 1) integration of I-PASS handoff in the Electronic Medical Record (EMR), 2) direct observation of the hand-off process by faculty and senior residents, and 3) surveillance and reporting of hand-off compliance scores. Compared to hand-off with a conventional method, the use of the I-PASS method resulted in significantly fewer reported adverse events (χ2=4.8, df=1, p=0.04). I-PASS was successfully integrated into our EMR system and residents were mandated to use this as the sole method of hand-off. An EMR audit conducted six months after implementation revealed poor compliance, which ultimately led to the creation of a sustainability model that improved overall compliance from 60% to 100%.</p>","PeriodicalId":91218,"journal":{"name":"BMJ quality improvement reports","volume":"6 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2017-04-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/49/6d/bmjqir.u222156.w8291.PMC5387931.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"34965538","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Improving Catheter Associated Urinary Tract Infection Rates in the Medical Units.","authors":"Haytham Taha, Salama J Raji, Abeer Khallaf, Seham Abu Hija, Raji Mathew, Hanan Rashed, Christelle Du Plessis, Zaytoen Allie, Samer Ellahham","doi":"10.1136/bmjquality.u209593.w7966","DOIUrl":"10.1136/bmjquality.u209593.w7966","url":null,"abstract":"<p><p>Sheikh Khalifa Medical City (SKMC) in Abu Dhabi is the main tertiary care referral hospital in the United Arab Emirates (UAE) with 560 bed capacity with a high occupancy rate. SKMC senior management has made a commitment to make quality and patient safety a top priority. Preventing health care associated infections, including Catheter Associated Urinary Tract Infection (CAUTI), is a high priority for our hospital. In order to improve CAUTI rates a multidisciplinary task force team was formed and led this performance improvement project. The purpose of this publication is to indicate the quality improvement interventions implemented to reduce CAUTI rates and the outcome of those interventions. We chose to conduct the pilot study in General Medicine as it is the busiest department in the hospital, with an average of 390 patients admitted per month during the study period. The study period was from March 2015 till April 2016. Our aim was to reduce CAUTI rates per 1000 device days in the medical units. Implemented interventions resulted in a reduction of CAUTI from 6.8 per 1000 device days in March 2015 to zero CAUTI in February through April 2016.</p>","PeriodicalId":91218,"journal":{"name":"BMJ quality improvement reports","volume":"6 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2017-04-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjquality.u209593.w7966","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"34965542","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Chasing the Golden Hour - Lessons learned from improving initial neutropenic sepsis management.","authors":"Caroline Forde,&nbsp;Paula Scullin","doi":"10.1136/bmjquality.u204420.w6531","DOIUrl":"https://doi.org/10.1136/bmjquality.u204420.w6531","url":null,"abstract":"<p><p>Neutropenic sepsis remains a time critical and potentially fatal complication of systemic anti-cancer therapy. A target 'door to needle' time of one hour for first dose empirical intravenous antibiotics continues to be promoted nationally. A baseline audit (June 2011) highlighted shortfalls in care in the Belfast Trust, with only 15% of patients receiving antibiotics within sixty minutes. A multi-professional group within the Trust was established to try and initiate the improvements in neutropenic sepsis recognition and initial management that were urgently required. A number of strategies have been developed over the last five years. Firstly an integrated care pathway was introduced, which is currently used by nursing and medical staff for patients presenting with suspected neutropenic sepsis, through acute cancer centre assessment areas and emergency departments, as well as inpatients developing neutropenic sepsis. An initial reaudit June 2012 demonstrated improvement (62% meeting 1hour target), but a subsequent audit, January 2013, was disappointing (only 50% meeting 1hour target). In response, a new compact, user-friendly care pathway was introduced. A range of other measures have also been subsequently introduced. Patients' care is continually monitored through simple ward based documentation, completed after initial treatment of each neutropenic sepsis episode. A patient group direction facilitates nurse led prescribing and administration of first dose antibiotics. Regular multidisciplinary education sessions and improved access to regional guidelines have also been prioritised. From November 2013, consistently greater than 80% of patients have met the one hour target. Recent data continues to be encouraging; in July 2016 100% of patients received first doses within sixty minutes, in October 95% of patients. Significant sustained improvements in meeting the sixty minute target have been demonstrated. The combination of measures ensures neutropenic sepsis is considered and basic clinical care delivered quickly and safely, through a co-ordinated standardised approach, to avoid complications.</p>","PeriodicalId":91218,"journal":{"name":"BMJ quality improvement reports","volume":"6 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2017-03-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjquality.u204420.w6531","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"34965541","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Improving the safety of chemotherapy prescribing in oncology through the introduction of an assessment proforma.","authors":"Paula Scullin,&nbsp;Olivia Devlin,&nbsp;Caroline Forde","doi":"10.1136/bmjquality.u216501.w7906","DOIUrl":"https://doi.org/10.1136/bmjquality.u216501.w7906","url":null,"abstract":"<p><p>Chemotherapy remains a high risk treatment with the potential to cause significant patient morbidity and mortality. In the UK the Manual for Cancer Services: Chemotherapy Measures provides national quality measures for essential elements that should be incorporated and documented in chemotherapy assessments. It was recognised that in the outpatient oncology chemotherapy unit in the Cancer Centre, Belfast City Hospital, Northern Ireland, that the written records of chemotherapy assessments were sub-optimal. At baseline (December 2015) median completion of chemotherapy assessment documentation was only 63%, based on a scoring system incorporating key assessment parameters from the Manual for Cancer Services and Belfast Trust standards for record keeping. A target of median chemotherapy assessment documentation being at least 95% complete was set. A paper chemotherapy assessment proforma was developed and introduced over an eight month period, using small tests of change and continuous data collection and feedback. The proportion of chemotherapy assessments documented using the proforma increased, as it was adjusted to be more user friendly and particularly after it started being pre-filed in medical notes. Increased use of the proforma correlated with improvement in completeness of chemotherapy assessment documentation. From week 29 to project completion (week 33), following proformas being routinely pre-filed and uptake increasing, assessments were on average 97% complete. Documentation of a patient's performance status, a critical aspect of the assessment, also improved to a median of 99% over the last seven weeks of the project from a baseline of 88%. The proforma has been positively viewed by staff with 94% agreeing it promotes safety. The introduction of a chemotherapy assessment proforma is a simple measure which can result in improved documentation of chemotherapy assessments, including performance status. It also serves as a prompt for safe decision making regarding chemotherapy prescriptions, enhancing the quality of outpatient chemotherapy care being delivered.</p>","PeriodicalId":91218,"journal":{"name":"BMJ quality improvement reports","volume":"6 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2017-03-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjquality.u216501.w7906","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"34966403","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}