eLetters

114 e-Letters

  • Pressure injury documentation: the case for using incident reports to inform quality improvement

    Pressure injuries are a largely avoidable adverse patient safety event, which are the focus of considerable global quality improvement efforts. Recent papers by Padula and Pronovost (1) and Squitieri et al. (2) highlight some of the challenges that exist with regards to efforts prevent and reduce the extent of patient harm arising from pressure injuries. These challenges include inconsistent reporting of the extent of pressure injury related harm as evinced by differences in the pressure injury related documentation from different care settings (1, 2) which are thought to be due to financial penalties for nosocomial pressure injuries (1). Padula and Pronovost (1) highlight the fact that the majority of the measurement and reporting of pressure injuries as well as the financial penalties for pressure injuries focus on hospital settings when pressure injury can arise at any point during a patient’s care trajectory. A number of possible solutions are put forward by Padula and Pronovost (1) to avoid underreporting the true extent of pressure injuries and to generate more accurate data that can be used to prevent and reduce the number of patients with pressure injuries in hospitals and other care settings. However, it is worth reflecting on the challenges of measurement and reporting for quality improvement and to considering what other routinely collected pressure injury related data can be used to inform improvement efforts.
    Establishing systems in which patient harm i...

    Show More
  • Health technology: boon or bane?

    I read this paper1 first published on 5 March 2018 in your journal with great interest.

    The great pace of health information technology (health IT) advancement in recent decades held promise in improving patient safety and quality of care, but unfortunately there has since been inadvertent consequences and carry-over effects of technology-related safety concerns in its use and implementation.2 This paper has further fuelled the boon or bane debate of health IT.3

    Ironically, the implementation of a national, multifaceted, quality improvement (QI) programme of ‘de-implementing’ electronic health record (EHR) notifications to primary care physicians (PCPs) has shown some benefit.1 This has, in some way, proven that being too reliant on technology in healthcare may yet rear its ugly head.

    The paper has shown that high volume of EHR notifications can overwhelm PCPs;1 the proposed measure of breaking these down into “low-value” and “high-value”, and enforcing certain mandatory ones, may merely be an intermediate stopgap technique. Determining which is which, by its nature, is difficult to do and standardise.

    Further, implementing a nationwide programme such as this poses certain challenges that the authors have not considered – will there be a difference between urban and rural healthcare facilities in its implementation, given resource limitations?4 Will technology have improved or changed by the time this programme is fully implemented nationwide?...

    Show More
  • Letter to the Editor

    To the editor,

    Sexton et al describe an observed association between leadership WalkRounds (WR) with feedback and improved levels of safety culture within healthcare settings.1 This work builds on previous data from this group evaluating WR in building a safety culture.2 These encouraging findings spur the need for understanding the robustness of evidence that the WR concept is built on in order to evaluate if continuation and expansion of the WR concept should be promulgated.

    The research data that WR are based on are largely observational sets or pre and post studies without control groups or objective outcome measures.3 This is fertile ground for bias and confounding that will undermine the probity of the findings. Sources of bias relate to institutional incentives around WR programs succeeding and the want held by individuals to be seen to be implementing initiatives that improve quality. In the present study described by Sexton et al, the cross sectional observational nature of the data collection is exposed to confounding with clinicians involved in a WR program potentially working in an environment with a superior safety culture regardless of the presence of regular WR (with or without feedback).1 Self-selection bias will also be at play as it is with any voluntary survey method as will be recall bias with culturally high achieving environments and poorly functioning settings over and under estimating their performance respectively, and perhaps ascribi...

    Show More
  • Authors' conclusions not supported by results

    Authors do not acknowledge some of the most common criticisms of these studies:

    (1) Physician health program (PHP) data may be suspect because PHPs benefit from presenting a rosy picture of their effectiveness.

    (2) Self-reports from those being evaluated by PHPs, which have much to lose from responding to surveys in ways that criticize these programs, may not be reliable.

    (3) There are considerable reasons to doubt that "programme completion," "return to practice," and "no relapse/recurrence" reflect treatment efficacy. Unwarranted referrals may also result in coerced treatment for physicians who do not have a substance use disorder or problematic performance, making "graduation" not meaningful for the purposes of drawing conclusions about PHP treatment effectiveness.

    Other concerns with this research will be addressed in forthcoming publications by the commentator.

  • What about compassion fatigue?

    Thank you for this article it summarises the situation well but omits to mention compassion fatigue in any detail . This is an important concept in organisations who need to change and recognise individual coping skills and support people to make positive changes in their own lives. Without self compassion we cannot be compassionate towards others. So whatever changes are made to the organisation it will not make any difference if people are not supported to change themselves. See this article - When Caring Stops Staffing Does Not Really Matter - https://www.nursingeconomics.net/necfiles/staffingUnleashed/su_ND10.pdf Or see my blog for more discussion on self compassion - http://drmarjorieghisoni.edublogs.org/

  • How do hospital boards use information for quality improvement?

    Thank you very much for your letter. We agree that the Schmidtke et al paper is highly relevant. In our discussion we note that 'recent research has emphasised the importance of meaningful representation and interpretation of data by boards', citing the accompanying editorial by Mountford and Wakefield which provides an overview both of the Schmidtke et al paper and another paper from the same issue by Anhøj et al on 'Red Amber Green' stoplight reports.

  • How do Hospital boards use information for quality improvement

    Thanks to the authors for this insight. I wondered if they had seen this content http://qualitysafety.bmj.com/content/26/1/61 from Schmidtke et al. which deals with how boards are presented with data, including the consideration of chance (common cause variation). The material seems highly compatible.

  • Addressing challenges of measurement

    To the Editor,

    Badawy et al describe, using statistical analysis, potential inaccuracy in the recording of respiratory rates (RR) in a large cohort of inpatients across a range of inpatient settings and add to the body of data suggesting widespread inaccuracy in the measurement of RR.1 The accurate recording of RR is an important safety and quality issue and the data provided by Badawy et al further underlines the challenges with measurement of this parameter in the inpatient setting.2 Having elegantly demonstrated the problem, the extension of this finding is a need to explore what methods can be potentially employed to improve the accuracy and recording of RR measurement.

    Several potential validated solutions may be adduced to address the deficiency in accurate RR measurement and recording. First, consideration could be given to introduction of a system of audit whereby healthcare workers are observed recording RR measurements during their routine practice. Despite a likely Hawthorne effect, the results of this can be collated then non-punitively and anonymously presented to organizational governance structures and health care workers. This concept has been successfully applied into staff hand hygiene quality improvement implementation with this approach having been shown to improve staff performance in this domain with an attendant systematic reduction in adverse event rates.3

    Second, the provision of technological solutions, such as a touch pad ba...

    Show More
  • A simple example of a practical solution to make patient-feedback more useful

    With great interest we read the article of Flott et. al. (1), describing the challenges of using patient-reported feedback. We recognize the challenges described and performed a bachelorproject in the intensive care unit (ICU) in the University Medical Center Groningen (UMCG). We think the results from our project provide a potential promising practical solution to make feedback more useful.
    In 2013 the UMCG participated in an independent multi-center study conducted among relatives of ICU patients (2). In the open questions of the questionnaire more dissatisfaction than expected was found, which fueled the quest for an alternative, simple and continuous feedback system. In this study we compared the quality and amount of feedback gathered by an oral survey during the first two weeks and an app during the consecutive two weeks.
    Between February 20th and March 18th 2017, patients above sixteen years old, listed for discharge from the ICU that day and their relatives were approached to participate in this study. The oral survey consisted of two simple questions: “How satisfied are you with your stay in the ICU? (grade 1-10)” and ”Do you have specific suggestions of improvement for the ICU?”. The RateIt app (Rate It Limited®, Hong Kong) was used consisting of the same two questions as in the oral survey.
    A total of 208 responses (133 patients and 75 relatives) were included. The median satisfaction score was 8. Despite this high score many suggestions for...

    Show More
  • SPC and Complexity

    As you point out Root Cause Analysis will often fail with hospital adverse event (AE) data because it was not designed to deal with data arising in a complex system.1 The same can be said for Pareto analysis. Statistical process control (SPC) methods are often used to summarise AE data, particularly hospital infection data such as surgical site infections (SSIs) and bacteraemias.2 Standard SPC also frequently fails to summarise these complex data correctly.
    With binary SSI data an approximate expected rate is frequently available so cumulative observed minus expected and CUSUM analysis are appropriate.2 However, the changing observed rate is not seen unless the numbers of procedures is large enough for them to be grouped by months or quarters. This is often infrequent. Even when such aggregation is possible difficulties arise as the number of procedures in each month may differ markedly. This problem can be dealt with, at least approximately, by employing a generalised additive model (GAM) analysis to the binary data that predicts the observed AE rate at various places in the time series.
    Count and rate data such as bacteraemias or new isolates of an antibiotic-resistant organism will usually not have an expected rate available. These data are often grouped by months and a Shewhat chart used for their display. This chart requires a stable centre-line about which reliable control limits can be drawn. Often the mean value is used as the expected rate even though...

    Show More

Pages