To assess the effect of a Crew Resource Management (CRM) intervention specifically designed to improve teamwork and communication skills in a multidisciplinary obstetrical setting.
Design-A before-and-after cross-sectional study designed to assess participants' satisfaction, learning and change in behaviour, according to Kirkpatrick's evaluation framework for training programmes. Setting-Labour and delivery units of a large university-affiliated hospital. Participants-Two hundred and thirty nine midwives, nurses, physicians and technicians from the department of anaesthesia, obstetrics and paediatrics. Intervention-All participants took part in a CRM-based training programme specifically designed to improve teamwork and communication skills. Principal measures of outcome-We assessed participants' satisfaction by means of a 10-item standardized questionnaire. A 36-item survey was administered before and after the course to assess participants' learning. Behavioural change was assessed by a 57-item safety attitude questionnaire measuring staff's change in attitude to safety over 1 year of programme implementation.
Most participants valued the experience highly and 63–90% rated their level of satisfaction as being very high. Except for seven items, the 36-item survey testing participants' learning demonstrated a significant change (P < 0.05) towards better knowledge of teamwork and shared decision making after the training programme. Over the year of observation, there was a positive change in the team and safety climate in the hospital [odds ratio (OR) 2.9, 95% confidence interval (CI) (1.3–6.3) to OR 4.7, 95% CI (1.2–17.2)]. **There was also improved stress recognition [OR 2.4, 95% CI (1.2–4.8) to OR 3.0, 95% CI (1.0–8.8)].
The implementation of a training programme based on CRM in a multidisciplinary obstetrical setting is well accepted and contributes to a significant improvement in interprofessional teamwork.
Despite good contraceptive coverage rates, recent studies in Iran have shown an alarmingly high incidence of unplanned pregnancy.
To determine factors affecting quality of family planning services, a cross-sectional study was performed from June to August 2006 on women visiting urban Primary Health Care clinics in a provincial capital in western Iran. The primary focus of the study was on provider–client interaction.
We used a slightly edited version of a UNICEF checklist and a convenient sampling method to assess quality of care in 396 visits to the family planning sections at 25 delivery points.
Poor performance was observed notably in Counselling and Choice of method sections. In logistic regression analysis, the following factors were found to be associated with higher quality of care: provider experience [OR (odds ratio) = 1.9, CI0.95 (confidence interval) = 1.2–3.0], low provider education (OR = 6.7, CI0.95 = 4.0–10.8), smaller workload at the clinic (OR = 3.7, CI0.95 = 2.0–6.7), and ‘new client’ status (OR = 4.2, CI0.95 = 2.6–6.7).
This study identified the issues of counselling and information exchange as the quality domains in serious need of improvement; these areas are expected to be the focus of future training programmes for care providers. Also, priority should be given to devising effective supervision mechanisms and on-the-job training of senior nursing and midwifery graduates to make them more competent in delivering basic family planning services.
To explore the association between implicit rationing of nursing care and selected patient outcomes in Swiss hospitals, adjusting for major organizational variables, including the quality of the nurse practice environment and the level of nurse staffing. Rationing was measured using the newly developed Basel Extent of Rationing of Nursing Care (BERNCA) instrument. Additional data were collected using an adapted version of the International Hospital Outcomes Study questionnaire.
Multi-hospital cross-sectional surveys of patients and nurses.
Eight Swiss acute care hospitals
Nurses (1338) and patients (779) on 118 medical, surgical and gynecological units.
Patient satisfaction, nurse-reported medication errors, patient falls, nosocomial infections, pressure ulcers and critical incidents involving patients over the previous year.
Generally, nurses reported rarely having omitted any of the 20 nursing tasks listed in the BERNCA over their last 7 working days. However, despite relatively low levels, implicit rationing of nursing care was a significant predictor of all six patient outcomes studied. Although the adequacy of nursing resources was a significant predictor for most of the patient outcomes in unadjusted models, it was not an independent predictor in the adjusted models. Low nursing resource adequacy ratings were a significant predictor for five of the six patient outcomes in the unadjusted models, but not in the adjusted ones.
As a system factor in acute general hospitals, implicit rationing of nursing care is an important new predictor of patient outcomes and merits further study.
To implement a prescribing-error reporting system in primary care offices and analyze the reports.
Descriptive analysis of a voluntary prescribing-error-reporting system
Seven primary care offices in Vermont, USA.
One hundred and three prescribers, managers, nurses and office staff.
Nurses and office staff were asked to report all communications with community pharmacists regarding prescription problems.
All reports were classified by severity category, setting, error mode, prescription domain and error-producing conditions.
All practices submitted reports, although reporting decreased by 3.6 reports per month (95% CI, –2.7 to –4.4, P < 0.001, by linear regression analysis). Two hundred and sixteen reports were submitted. Nearly 90% (142/165) of errors were severity Category B (errors that did not reach the patient) according to the National Coordinating Council for Medication Error Reporting and Prevention Index for Categorizing Medication Errors. Nineteen errors reached the patient without causing harm (Category C); and 4 errors caused temporary harm requiring intervention (Category E). Errors involving strength were found in 30% of reports, including 23 prescriptions written for strengths not commercially available. Antidepressants, narcotics and antihypertensives were the most frequent drug classes reported. Participants completed an exit survey with a response rate of 84.5% (87/103). Nearly 90% (77/87) of respondents were willing to continue reporting after the study ended, however none of the participants currently submit reports.
Nurses and office staff are a valuable resource for reporting prescribing errors. However, without ongoing reminders, the reporting system is not sustainable.
To translate and adapt the Critical Care Family Satisfaction Survey (CCFSS), and test its validity and reliability for use in Saudi Arabia.
Seven hundred-bed tertiary care hospital in Saudi Arabia.
Seventy-six adult relatives of patients who had been cared for in an intensive care unit for 24 hrs or more.
The CCFSS, a battery of 20 items divided into five subscales, was translated into Arabic. After transfer of patients to regular inpatient units, interviewers administered the survey to their next-of-kin. Respondents ranked their satisfaction with each item on a 5-point Likert scale.
Subscale scores were calculated as the average of the individual item scores. The total scale score was the sum of the subscale scores.
The total scale and ‘Information’, ‘Support’, ‘Comfort’ and ‘Assurance’ subscales showed acceptable internal consistency (Spearman's correlation coefficient of the total score with each of the subscale scores = 0.52–0.81, P < 0.01; Cronbach's alpha = 0.67–0.88). But the ‘Proximity’ subscale performed poorly (r = 0.48, P < 0.01; Cronbach's alpha = 0.36). Discriminant validity was tested with a Spearman's rank correlation matrix of the subscales, and ranged from weak between ‘Support’ and both ‘Assurance’ and ‘Information’ (r = 0.80) to substantial between ‘Information’ and ‘Proximity’ (r = 0.54) (P < 0.01).
This Arabic translation and adaptation of the CCFSS is a valid, reliable and feasible tool to evaluate family satisfaction in Saudi Arabian intensive care units.
One of the prime goals of any health system is to deliver good and competent quality of healthcare. Through World Bank-assisted Maharashtra Health Systems Development Project, Government of Maharashtra in India developed and implemented clinical indicators to improve quality.
During this, clinical areas eligible for monitoring quality of care and roles of health staff working at various levels were identified.
Brainstorming discussion sessions were conducted to refine list of potential clinical indicators and to identify implementation problems.
It was implemented in four stages. (a) Self-explanatory tool of record, standard operating procedures and training manual were prepared during tools preparation stage. (b) Pilot implementation was done to monitor the usefulness of indicators, document the experiences and standardize the system accordingly. (c) The final selection of indicators was done taking into consideration points like data reliability, indicator usefulness etc. For final implementation, 15 indicators for district and 6 indicators for rural hospitals were selected. (d) Transfer of skills was done through training of various hospital functionaries.
Selection and prioritization of clinical indicators is the most crucial part. Active participation of local employees is essential for sustainability of the scheme. It is also important to ensure that data recorded/reported is both reliable and valid, to conduct monthly review of the scheme at various levels and to link it with the quality improvement programme.
To compare the prevalence of pressure ulcers and prevention before and after a quality improvement program; determine whether patient characteristics differed for those who did and did not develop pressure ulcers; identify pressure ulcer prevention implemented at admission and whether prevention and risk factors varied by pressure ulcer severity.
Descriptive comparative study based on two cross-sectional pressure ulcer surveys conducted in 2002 and 2006, complemented with a retrospective audit of the electronic health record and administrative system for patients identified with pressure ulcers.
1100-bed Swedish university hospital.
612 hospitalized patients in 2002 and 632 in 2006.
Prevalence of pressure ulcers and prevention (pressure-reducing mattresses; planned repositioning; chair, heel and 30° lateral positioning cushions).
Pressure ulcer prevalence was 23.9% in 2002 and 22.9% in 2006. When non-blanchable erythema was excluded, the prevalence was 8.0 and 12.0%, respectively. The use of pressure-reducing mattresses increased while planned repositioning decreased. Those who developed ulcers were older, at-risk for ulcers, incontinent and had longer length of stay. Little prevention was documented at admission. Some prevention strategies and risk factors were related to severity of ulcers.
Pressure ulcer prevalence did not decrease, despite a comprehensive quality improvement program. Special attention is needed to provide prevention to older patients with acute admission. Skin and risk assessment, as well as prevention, should start early in the hospitalization. Identifying those persons with community-acquired versus hospital-acquired ulcers will strengthen pressure ulcers as an accurate marker of quality of care for hospitalized patients. If possible, data should be reported by ward level for comparison over time.
To evaluate the pilot implementation of the World Health Organization Performance Assessment Tool for Quality Improvement in hospitals (PATH).
Semi-structured interviews with regional/country coordinators and Internet-based survey distributed to hospital coordinators.
A total of 37 hospitals in six regions/countries (Belgium, Ontario (Canada), Denmark, France, Slovakia, KwaZulu Natal (South Africa)).
Six PATH regional/country coordinators and 37 PATH hospital coordinators.
Implementation of a hospital performance assessment pilot project.
Experience of regional/country coordinators (structured interviews) and experience of hospital coordinators (survey) with the pilot implementation.
The main achievement has been the collection and analysis of data on a set of indicators for comprehensive performance assessment in hospitals in regions and countries with different cultures and resource availability. Both regional/country coordinators and hospital coordinators required seed funding and technical support during data collection for implementation. Based on the user evaluation, we identified the following research and development tasks: further standardization and improved validity of indicators, increased use of routine data, more timely feedback with a stronger focus on international benchmarking and further support on interpretation of results.
Key to successful implementation was the embedding of PATH in existing performance measurement initiatives while acknowledging the core objective of the project as a self-improvement tool. The pilot test raised a number of organizational and methodological challenges in the design and implementation of international research on hospital performance assessment. Moreover, the process of evaluating PATH resulted in interesting learning points for other existing and newly emerging quality indicator projects.
The purpose of this study was to identify and analyze research into accreditation and accreditation processes.
A multi-method, systematic review of the accreditation literature was conducted from March to May 2007. The search identified articles researching accreditation. Discussion or commentary pieces were excluded.
From the initial identification of over 3000 abstracts, 66 studies that met the search criteria by empirically examining accreditation were selected.
The 66 studies were retrieved and analyzed. The results, examining the impact or effectiveness of accreditation, were classified into 10 categories: professions' attitudes to accreditation, promote change, organizational impact, financial impact, quality measures, program assessment, consumer views or patient satisfaction, public disclosure, professional development and surveyor issues.
The analysis reveals a complex picture. In two categories consistent findings were recorded: promote change and professional development. Inconsistent findings were identified in five categories: professions' attitudes to accreditation, organizational impact, financial impact, quality measures and program assessment. The remaining three categories—consumer views or patient satisfaction, public disclosure and surveyor issues—did not have sufficient studies to draw any conclusion. The search identified a number of national health care accreditation organizations engaged in research activities.
The health care accreditation industry appears to be purposefully moving towards constructing the evidence to ground our understanding of accreditation.
Assessing the quality of health care has become increasingly important in health care in response to growing demands from purchasers, providers, clinicians and the public. Given the increase in projects and programs to assess performance in health care in the last 15 years, the purpose of this paper is to review current indicator projects for hospital performance assessment and compare them to the Performance Assessment Tool for Quality Improvement in Hospitals (PATH), an initiative by the WHO Regional Office for Europe.
We identified current indicator projects through a systematic literature search and through contact with experts. Using an inductive approach based on a review of the literature, we identified 10 criteria for the comparison of indicator projects. We extracted data and contacted the coordinators of each indicator project to validate this information. In addition, we carried out interviews with coordinators to gather additional information on the evaluation of the respective projects.
We included 11 projects that appear to have adopted a common methodology for the design and selection of indicators; however, major differences exist with regard to the philosophy, scope and coverage of the projects. This relates in particular to criteria such as participation, disclosure of results and dimensions of hospital performance assessed.
Hospital performance assessment projects have become common worldwide, and initiatives such as the WHO PATH project need to be well coordinated with existing projects. Our review raised questions regarding the impact of hospital performance assessment that should be pursued in further research.
Patients' satisfaction with cancer care has not been studied in detail in the South-Asian region in spite of rising cancer incidence.
To validate the ‘Sinhala’ translation of the European Organization for Research and Treatment of Cancer (EORTC) in-patient satisfaction with care questionnaire (IN-PATSAT32) in Sri Lanka.
We administered the translated version of the IN-PATSAT32 on 343 newly diagnosed adult in-patients with cancers of head and neck, breast, oesophagus, cervix uteri and lung, recruited from seven tertiary care oncology treatment centres in the District of Colombo. Patients with previous cancer diagnoses, too frail/mentally unfit, with evidence of brain metastases and unable/unwilling to give informed consent were excluded. Psychometric testing assessed the hypothesized scale structure, scale reliability, construct validity and acceptability of the IN-PATSAT32.
A high response rate (100%) and low missing data (0.05%) confirmed the acceptability of the IN-PATSAT32. The hypothesized scale structure was confirmed with 100% item-convergent and 98.6% item-discriminant validity, and a scaling success rate, defined as items correlating significantly higher (more than 1.96 standard errors) with its own scale (corrected for overlap) than with another scale, of 97.9%. The Cronbach's alpha coefficient for internal consistency exceeded 0.70 in all scales. Construct validity was confirmed with inter-scale correlations, which were all statistically significant (P < 0.01) and were of moderate-to-high magnitude, evidence that they were measuring distinct dimensions of patient satisfaction.
The translated version of the IN-PATSAT32 has proved to be a reliable and valid measure of satisfaction with cancer care in patients with heterogeneous cancer diagnoses in Sri Lanka.
Adverse drug events are leading categories of iatrogenic patient injury. Development of preventive strategies for general practice setting depends on effective detection of events.
The aim of the study is to compare the strengths and weaknesses of voluntary reporting, chart review and patient survey in measuring medication misadventures in general practice and to analyze the events by severity and preventability, drug groups and patients' and doctors' characteristics, for the formulation of preventive strategies.
In the 2-month study period, we applied voluntary report, chart review and patient survey to collect data related to medication misadventures and compared their detection rate.
The chart review demonstrated the highest yield for detecting overall medication misadventures (2.03% medication orders), followed by patient survey (1.46% medication orders) and voluntary reporting (0.52% medication orders). Chart review and patient survey were better than voluntary reporting in uncovering preventable adverse drug events. However, voluntary reporting was pivotal in capturing sentinel events. Beta-blocker, diuretic, angiotensin-converting enzyme inhibitor, aspirin and non-steroidal anti-inflammatory drugs had caused 82.0% of all adverse drug events. These events were more common with advanced age of patients, greater number of consultation problems and prescribed drug items. Additional resources implicated were minimal.
We suggested a complementary approach using chart review and voluntary reporting in measuring and monitoring medication misadventures in general practice. Close monitoring of the events was necessary for older patients, multiple medical problems and poly-pharmacy and for patients using beta-blocker, diuretic, angiotensin-converting enzyme inhibitor, aspirin or non-steroidal anti-inflammatory drugs on a long-term basis.
An electronic Incident Information Management System implemented system-wide by the Department of Health, New South Wales, Australia was evaluated. We hypothesized that health professionals (i) would support the system via utilization and favourable attitudes and (ii) that their usage and attitudes would vary according to profession with nurses being most, and doctors least, favourably disposed.
An online, anonymous questionnaire survey of 2185 health practitioners.
Undertaking system training, satisfaction with training, reporting incidents, incident reporting rates since system introduction and attitude questions focusing on use, security and evaluation of the system and workplace safety cultures.
The first hypothesis received partial support. The majority of respondents had undertaken training and rated it highly. Most had reported incidents and maintained their previous reporting levels. Most attitudes regarding using the system and its security were favourable. Mixed attitudes were held about workplace safety cultures and the value of the system. Deficiencies in quality of reporting, feedback on incident reports and resources to analyse incident data were problems identified. The second hypothesis was confirmed. Nurses were most, and doctors least, likely to undertake training, report incidents and express favourable attitudes. Allied health responses were intermediate to those of the other professions.
The system implementation was relatively successful, but more so with some professions. Problems identified indicated that expectations as to the goals achievable in the short term were optimistic, but these are amenable to planned interventions.
There are limited published data on the labelling of single unit dose packages in hospitals.
The study was conducted in three large hospitals (two adult and one paediatric) in the metropolitan Montreal area, Quebec, Canada.
The objective is to evaluate the labelling of commercial oral single solid unit dose packages available in Canadian urban hospital pharmacy practice.
The study endpoint was the labelling conformity of each unit dose package for each criterion and overall for each manufacturer. Complete labelling of unit dose packages should include the following information: (1) brand name, (2) international non-proprietary name or generic name, (3) dosage, (4) pharmaceutical form, (5) manufacturer's name, (6) expiry date, (7) batch number and (8) drug identification number. We also evaluated the ease with which a single unit dose package is detached from a multiple unit dose package for quick, easy and safe use by pharmacy staff. Conformity levels were compared between brand-name and generic packages.
A total of 124 different unit dose packages were evaluated. The level of conformity of each criterion varied between 19 and 50%. Only 43% of unit dose packages provided an easy-to-detach system for single doses. Among the 14 manufacturers with three or more unit dose packages evaluated, eight (57%) had a conformity level less than 50%.
This study describes the conformity of commercial oral single solid unit dose packages in hospital pharmacy practice in Quebec. A large proportion of unit dose packages do not conform to a set of nine criteria set out in the guidelines of the American Society of Health-System Pharmacists and the Canadian Society of Hospital Pharmacists.
Mortality data has often been used to monitor the quality of cardiac care.
To investigate the under-reporting of unnatural deaths in mortality data.
All patients with a main discharge diagnosis of injury (ICD-9-CM code 800–999) who died in 2003 or 2004 were identified through record linkage between hospital discharge claims data and cause of death data in Taiwan. Percentages of unnatural deaths that had been referred to the coroner and in which injury-related information was reported on the death certificate were estimated.
Of 4086 known or suspected unnatural deaths, only 57% (2346/4086) were referred to the coroner, and in 71% (2889/4086) injury-related information was reported on the death certificate. The percentages of referral and reporting were lowest for deaths related to complications in medical and surgical care. In deaths related to fracture of the femur and the effects of a foreign body, many doctors report injury-related information on the death certificate but do not refer the certification of cause of death to the coroner.
The sensitivity of using mortality data alone to detect known or suspected unnatural deaths varied according to the types of injury and external causes. Monitoring cause of death data linked with hospital discharge record data could provide a better system for discovering these unnatural deaths.
Although patient safety climate is an important factor in preventing adverse events in health care organizations, there is no usable Japanese scale.
To develop a Japanese scale to measure patient safety climate and to evaluate its psychometric properties.
Cross-sectional questionnaire survey was conducted with respect to 9 non-academic general hospitals in Japan. A total of 1878 health care professionals (nurses, therapists, technicians, pharmacists and physicians) were included in a study.
The eight dimensions measuring worker attitudes (free communication flow, continuous improvement, reporting/rules compliance and patient/family involvement) and organizational factors (supervisors' safety leadership, allied professionals' safety leadership, patient safety committee leadership and rules/equipment availability) were extracted by factor analysis. The internal consistency (measured by Cronbach's alpha) and repeatability (measured by intraclass correlation) were more than 0.70 for all subscales. In addition, the mean score, the within-group interrater reliability statistic (rwg) and the correlation coefficients of the mean score were confirmed at the workplace level.
The scale showed acceptable dimensionality, reliability and validity. It also provided workplace team-evaluation and a tool for assessing the patient safety climate at the level of the workplace.