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The safety imperative to transform health care
Despite extensive efforts in many countries, safe health care continues to be elusive. Old patterns persist. To reach the levels of safety that we already know how to provide requires not just improvement; but transformation. This issue of QSHC advances a call from a group of US healthcare improvement and safety leaders to adopt five concepts that they consider essential to this transformation. This call is accompanied by an editorial and commentaries from colleagues in France and Australia. The concepts include the following: 1) Transparency must be universal. 2) Care must be delivered by multidisciplinary teams who work in integrated care platforms. 3) Patients must become full partners in all aspects of health care. 4) Health care workers need to find joy and meaning in their work. 5) Medical education must be redesigned to prepare new physicians to function in this changed environment. These transformative strategies comprise a major culture change for health care. Achieving them will require enlightened leadership and support from all stakeholders.
Champions and their complex role in infection prevention
More than 20% of healthcare-associated infections can be prevented, but many hospitals have not implemented practices known to reduce infections. This probing report explores the role for champions in a qualitative analysis of interviews and site visits of a geographically diverse sample of US hospitals. Technology implementation differs from behavioural change in this regard. Findings point to the value of a single well-placed champion to implement a new technology; but more than one champion was needed when an improvement required people to change behaviours. While the behaviour change itself may appear to be inexpensive compared to buying more expensive technology, implementation was often more complicated because behaviour changes required inter-professional coalitions of staff working together effectively. Champions in hospitals with low quality working relationships across units or professions had a particularly challenging time implementing behaviour changes. Even when broad implementation is stymied, however, champions can still implement change within their own domain of control.
See pages 434
The continuing challenge of hand hygiene in health care workers
Despite the importance of hand hygiene in reducing infection, healthcare worker compliance remains low. This report describes a multimodal interventional study in five hospital units in Florence, Italy. Direct observation of doctors and nurses focused on hygiene before touching the patient. Overall hand hygiene increased from 31.5% to 47.4% (p = 0.001). Patient units differed in the magnitude of their improvement. Based on interviews, variability appeared related to the ‘‘champion’’ on each unit, as well as the level of motivation each physician leader exhibited when pre-intervention results were provided. Although adherence increased after the intervention, considerable variability—for both nurses and doctors and across the 5 units—was seen. An accompanying commentary asks what it will take to move health professionals to universal hand hygiene.
Impact of a standard medication chart on prescribing errors
A standardised paper-based medication chart was developed by a multidisciplinary collaborative across Queensland, Australia. Previously there were 23 different charts. Variability within and between hospitals was an opportunity for error due to unfamiliarity with the systems. The new chart included structural changes to increase the access to decision support and reduced the risk for nurse interpretation of dosing instructions. This study in five sites was associated with a significant reduction in prescribing error rate from 20% to 15.8% of orders per patient. The chart has now been implemented across Queensland and forms the basis of the national in-patient medication chart for Australia.
See pages 478