I agree that every opportunity should be taken to discuss with
patients with diabetes how they can reduce the risk of complications, and
that screening can present one such opportunity. However, because the
effectiveness of this approach has not been tested in an RCT, it was not
included in the review on which this Effective Health Care Bulletin was
based.
Dear Sir,
We read with interest the article by Schmidt et al. We applaud the authors for undertaking this large and complex study and for highlighting the great potential of newer technologies to improve patient care.
We hoped the authors could clarify some key issues. Firstly only one year's mortality data are used as a baseline comparator. Mortality fluctuates by year as this paper highlights, and can be affected by a large...
Dear Sir,
We read with interest the article by Schmidt et al. We applaud the authors for undertaking this large and complex study and for highlighting the great potential of newer technologies to improve patient care.
We hoped the authors could clarify some key issues. Firstly only one year's mortality data are used as a baseline comparator. Mortality fluctuates by year as this paper highlights, and can be affected by a large number of factors including how it is expressed (1). It is possible that the year chosen may have been an outlier that triggered the Trusts to actively invest in measures including EPSS. We would therefore be grateful if the authors could provide additional data on mortality in the years prior to the intervention. Were other strategies employed alongside EPSS? For example we understand University Hospital Coventry also called in Dr Foster Intelligence in 2007 to restructure practice (2).
As the paper uses only a historical comparator it is possible that a proportion of the improvement reflects the general national improvement in hospital mortality seen over the last decade (3). Do the authors have any data comparing their improvements with other Trusts of a similar size, case-mix, and similarly average HSMR (4)?
Interventions in healthcare are rarely without some adverse effects and as such we would be interested in any data collected on the potential negative aspects. These would include consequences of the increased workload for junior doctors and financial effect cost. Establishing that these were relatively minor would be very reassuring for other Trusts considering similar strategies.
While we agree that randomised controlled trials are complex, we suggest there is a strong rationale for them to disaggregate the benefit of EPSS from many confounding factors, and to inform clear health economic analysis.
Yours sincerely,
Dominick Shaw, John Blakey and Jamie Rylance
1 http://www.nejm.org/doi/full/10.1056/NEJMsa1006396#t=articleMethods
2 http://drfosterintelligence.co.uk/wp-content/uploads/2013/02/University-Hospitals-Coventry-Warwickshire-NHS-Trust-case-study.pdf
3 http://www.biomedcentral.com/1472-6963/13/216
4 http://drfosterintelligence.co.uk/wp-content/uploads/2011/11/Hospital_Guide_2011.pdf
Grogan et al[1] report that their Patient Satisfaction Questionnaire
(PSQ) is a valid and internally reliable tool for assessing patient
satisfaction with primary care services despite the acknowledgement in
their discussion that further research is required to confirm other
aspects of reliability and validity. We feel that their conclusion is
premature.
Grogan et al[1] report that their Patient Satisfaction Questionnaire
(PSQ) is a valid and internally reliable tool for assessing patient
satisfaction with primary care services despite the acknowledgement in
their discussion that further research is required to confirm other
aspects of reliability and validity. We feel that their conclusion is
premature.
Having recently been involved in the validation of a postal
questionnaire to assess quality of life in dyspeptic patients we are aware
of the importance of a full evaluation. Our principal concerns with the
published study[1] relate to the lack of information relating to
representativeness and acceptability. The need to demonstrate
acceptability is heightened when questionnaires are to be self-completed.
Response rate data were not provided because of the study design. Response
rates give not only an indication of the acceptability of the questions
used, but also provide information about the acceptability of the concept,
e.g. will patients answer questions about their doctor? Full data sets
were available for 1151/1390 returned questionnaires; 17% of patients
chose not to complete all questions, which may indicate lack of
acceptability of certain items. Acceptability is important for several
reasons:
1) ethically we should not be utilising tools which may
distress/offend
2) financially we should not use a tool which will not be
returned or where intense effort is required to generate responses
3) in the interests of quality we should not use a tool where differential
acceptability may cause bias.
Before recommending the PSQ as a tool we
would like to see some evidence that acceptability has been demonstrated
in different patient groups.
Other evidence that would be useful before concluding that the
questionnaire should be adopted includes data on reproducibility
(consistency of response) and responsiveness over time. Before using the
questionnaire for repeated audit or to evaluate change in practice, it is
important to confirm that the questionnaire is able to reflect changes in
satisfaction over time.
Whilst the data provided indicates the PSQ to be valid and reliable,
these data must be interpreted with some caution given the lack of
information about sample selection and representativeness. Other issues
pertinent to questionnaire evaluation have not been fully explored and,
given that this is designed to be a self-completion questionnaire for use
in an area in which traditionally patients have not been consulted,
acceptability of the questionnaire and individual questions should be
assessed before concluding that the tool be adopted.
Reference
(1) Grogan S, Conner M, Norman P, Willits, Porter I. Validation of a
questionnaire measuring patient satisfaction with general practitioner
services. Quality in Health Care 2000;9:210-15
I have recently returned from the Association of Simulated Practice in Healthcare 2014 conference in Nottingham and whilst there was privileged to hear and meet Professor Erik Hollnagel. He presented eloquently on his work relating to “From Safety I to Safety II” [1] which provided an excellent opening for the conference’s theme of “Changing Behaviours.” His work sparked much debate and reflection, part...
I have recently returned from the Association of Simulated Practice in Healthcare 2014 conference in Nottingham and whilst there was privileged to hear and meet Professor Erik Hollnagel. He presented eloquently on his work relating to “From Safety I to Safety II” [1] which provided an excellent opening for the conference’s theme of “Changing Behaviours.” His work sparked much debate and reflection, particularly by myself when presenting our simulation work related to the Duty of Candour. We opened with a discussion considering how the NHS was perceived by the general population of the UK. The conversation moved to the role of the media in driving the campaign for patient safety and openness.
The media has embraced the reports of a small number of high profile failings in the NHS, with the now daily reporting of another “failure” or “cover-up”. It is therefore understandable why a large proportion of the population do not trust the NHS and feel there is a closed and dishonest culture [2]. The media focuses on the Safety I premise of failures [1]. This is driving the destruction of the NHS’s reputation and the wellbeing of staff and patients by focusing on the minority of outcomes which are negative. In November 2013, our local Trust was reported to be the second worst general hospital in England for avoidable deaths [3]. A review of the data and response from the Trust identified that the news report was misleading and the data inaccurate, causing unnecessary anxiety amongst patients and staff [4]. Such media reports place extra strain on the healthcare system with reputational damage and effects on morale which effect the ability of that organisation to sustain required operations.
However, now 12 years later, the focus still remains on the serious errors, incidents and failures of the NHS. These events are still the minority of events, but the focus remains on what went wrong. As it is time for healthcare to focus on Safety II, should it not be the same for the media? By focussing on what goes right and the NHS's incredible ability to succeed under varying conditions, the media can celebrate the NHS and help to drive the next stage of safety improvement. It is time for
the media to also move from Safety I to Safety II thinking.
The discussion regarding media involvement in the NHS prompted me to consider this further and I read with great interest the 2002 paper published in BMJ Quality and Safety considering the role of the media in pushing patient safety forward as the priority [5]. There is no doubt that media involvement has benefitted the patient safety agenda, by acting as a “watchdog” to hold the medical profession accountable for improved safety and quality of care. This in turn has created a passionate group of healthcare professionals striving for excellence in care.
12 years later, however, the focus still remains on the serious errors, incidents and failures of the NHS. These events are still the minority of events, but the focus remains on what went wrong. As it is time for healthcare to focus on Safety II, should it not be the same for the media? By focussing on what goes right and the NHS’s incredible ability to succeed under varying conditions [1], the media can celebrate the NHS and help to drive the next stage of safety improvement. It is time for the media to also move from Safety I to Safety II thinking.
The difficulty will be in convincing the media of its role in the next stage of safety. It remains important for the NHS to be transparent, but a balance must be sought between the ongoing need for accurate reporting of serious problems and celebration of the NHS’s staff and its successes. In a recent well known report on health and healthcare service delivery [6], the UK ranked number one against ten other wealthy countries for overall healthcare (based on quality, access, efficiency and equity).
Professor Hollnagel defined resilience as the ability of the healthcare system to adjust its functioning to sustain operations under both expected and unexpected conditions [1]. The media must understand the complexity of the NHS and be aware of the potential for their reporting to inadvertently remove those parts of the healthcare system that have contributed to its resilience.
1) Hollnagel E. Safety I and Safety II: The Past and Future of Safety
Management. Ashgate: Surrey, United Kingdom
2) YouGov UK. One in two don’t trust the NHS. [Online] 2013. Available from: https://yougov.co.uk/news/2013/06/13/1-2-do-not-trust-nhs/ [Accessed 14th November 2014].
3) Adams S. How 3,500 hospital patients lost their lives due to surgical errors or staff who were too busy to treat them... in just TWELVE months. The Mail on Sunday. [Online] November 09 2013. Available from: www.dailymail.co.uk [Accessed 14th November 2014].
4) Nottingham University Hospitals NHS Trust. Response to Mail On Sunday coverage (avoidable deaths). [Online: media response] 2013. Available from: http://www.nuh.nhs.uk/media/1459425/response_to_mail_on_sunday_coverage.pdf [Accessed 14th November 2014].
5) Millenson ML. Pushing the profession: how the news media turned patient safety into a priority. Qual Saf Health Care 2002; 11: 57–63.
6) Davis K, Stremikis K, Schoen C, Squires D. Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally. The Commonwealth Fund. 2014.
Roberts et al[1] provide a commentary on the Patient Satisfaction
Questionnaire (PSQ) that we have developed and validated.[2][3] Whilst
they accept that the PSQ is a valid and internally reliable tool for
assessing patient satisfaction with primary care services, they suggest
that further work is required before the measure is adopted. In
particular they point to the need to assess the acceptabi...
Roberts et al[1] provide a commentary on the Patient Satisfaction
Questionnaire (PSQ) that we have developed and validated.[2][3] Whilst
they accept that the PSQ is a valid and internally reliable tool for
assessing patient satisfaction with primary care services, they suggest
that further work is required before the measure is adopted. In
particular they point to the need to assess the acceptability of the items
to different patient groups.
In the development of a measure such as the PSQ, continuing
assessment of reliability, validity and acceptability is clearly
worthwhile. Nevertheless we would argue that there already exists
sufficient data on the reliability and validity of the scale[2][3] to
warrant its adoption as means of assessing patient satisfaction with
primary care services.
In relation to the specific points raised by Roberts et al[1]:
First, in relation to the issue that certain items may be
unacceptable and produce low response rates. Analysis of items included in
both the original study where the questionnaire was developed[2] and the
validation study[3] has failed to show any differences in response rates
on individual items. Also, all items originated in interviews and open-ended questionnaires with patients, and we have no reason to believe that
they would be unacceptable to other patients.
Second, in relation to whether particular items may distress or
offend respondents. As all items were originally derived from interviews
with patients, the wording reflects the way in which patients talk about
these services. In reproducing the questionnaire we allow practitioners
the opportunity to judge the potential offensiveness of the items. We have
not received any negative feedback about items from practitioners or
respondents to the questionnaires used in our validation study in terms of
their distressing nature or offensiveness. There is no evidence to
support the suggestion that any of the items in the PSQ will distress or
offend respondents.
Third, in relation to the suggestion that the PSQ as a whole may not
be completed by particular groups: This is not an issue we have
specifically addressed in our research. To do so would require the
assessment of response rates in different groups where we might expect
differences. A further analysis might then compare the numbers of fully
versus partially completed PSQs. In relation to this latter point, from
the data reported in Grogan et al,[3] we were able to make a comparison
of questionnaires that were fully completed versus those that were only
partially completed. This indicated no significant impact of various
demographic groups (eg, age, gender) on completion rates.
In summary, whilst we accept that further work to assess the
reliability, validity, and acceptability of the PSQ is warranted, we
believe that the measure has been sufficiently tested to make it suitable
for adoption by those wishing to assess patient's satisfaction with
primary care services.
Sarah Grogan, PhD (Address for correspondence)
Senior Lecturer
Department of Psychology and Speech Pathology
Manchester Metropolitan University
Elizabeth Gaskell Building
Manchester M13 OJA, UK
Mark Conner, PhD
Senior Lecturer
School of Psychology
University of Leeds
Leeds LS2 9JT, UK
References
(1) Roberts L, Roalfe A, Wilson S. Patient Satisfaction Questionnaire
- Further validation required [Rapid Response]. Qual Health Care 22
December 2000. http://www.qualityhealthcare.com/cgi/eletters/9/4/210#EL1
(2) Grogan S, Conner M, Willits D, Norman P. Development of a
questionnaire to measure patients' satisfaction with general
practitioners' services. British Journal of General Practice 1995;45:525-
29.
(3) Grogan S, Conner M, Norman P, Willits, Porter I. Validation of a
questionnaire measuring patient satisfaction with general practitioner
services. Qual Health Care 2000;9:210-15.
Recently, Provenzano and colleagues found that an electronic tool
collecting real-time clinical information directly from front-line
providers was both feasible and useful to evaluate inpatient deaths [1].
These findings concur with our evaluation of the preventability of death
using a simple electronic evaluation tool in our 46-bed adult Intensive
Care Unit.
Recently, Provenzano and colleagues found that an electronic tool
collecting real-time clinical information directly from front-line
providers was both feasible and useful to evaluate inpatient deaths [1].
These findings concur with our evaluation of the preventability of death
using a simple electronic evaluation tool in our 46-bed adult Intensive
Care Unit.
From September 2010 to September 2011 an email was send to the
attending intensivist each time a patient died in our intensive care
including 2 questions: "Was this death preventable? If yes, what was the
cause of preventability?". The definition of preventable mortality was
provided using three criteria: the illness was survivable, care was
suboptimal, and suboptimal care was related to death. No reminding emails
were sent. In addition, the patient charts of all cases were
retrospectively reviewed by two ICU nurses and a physician.
A total of 306 patients (9.9%) died. APACHE IV Standardised Mortality
Rate was 0.77. In 48 of these deceased patients the APACHE IV based
mortality risk was below 20%. Response rate was 92% and 47 deaths (15%)
were reported to be potentially preventable. Large inter-individual
variations between the intensivists (n=24) were observed. Response varied
between 65% and 100% and preventable death judgments varied from none to
66%. When using blinded chart review was by the nurses and physician
judged death potentially preventable in 7%, 11%, and 18%, respectively.
Alike Provenzano et al. we also found poor agreement between the
preventability ratings from front-line intensivist reviews when compared
to blinded chart review [2]. In 21 cases (45%) in which the intensivist
scored a preventable death all three reviewers scored these non-
preventable. This might partly be explained by additional information on
each patient's individual circumstances that cannot easily be deduced from
patients' charts. Using APACHE IV as selection criterion for in-depth
evaluation is insufficient while analysis of patients with an APACHE IV
based risk of mortality below 20% showed that only 4 of these deaths
(8.3%) were considered potentially preventable [3].
Preventability of death evaluation of all inpatient deaths is
required either for quality improvement and/or by regulatory authorities.
A quick and efficient method with high response rates from front-line
providers is feasible and may provide useful information for quality
improvement [4]. However, large inter-individual variations in response
and judgment exist and, therefore, this method apparently is insufficient
for benchmarking.
References:
1. Provenzano A, Rohan S, Trevejo E, et al. Evaluating inpatient
mortality: a new electronic review process that gathers information from
front-line providers. BMJ Qual Saf 2015;24:31-37.
2. Hayward RA, Hofer TP. Estimating hospital deaths due to medical errors:
preventability is in the eye of the reviewer. JAMA 2001;286:415-20.
3. Girling AJ, Hofer TP, Wu J, et al. Case-mix adjusted hospital mortality
is a poor proxy for preventable mortality: a moddeling study. BMJ Qual Saf
2012;21:1052-1056.
4. Dijkema LM, Dieperink W, van Meurs M, et al. Preventable mortality
evaluation in the ICU. Crit Care 2012;16:309.
The provision of free access to the electronic versions of journals to
the users in the developing world deserves lots of praise, indeed. Coming
from such a background, I cannot over emphasize the long felt need for the
same.
Internet use, especially for medical education and training in India,
has increased by leaps and bounds over the last five years. In spite of
that, institutional subscr...
The provision of free access to the electronic versions of journals to
the users in the developing world deserves lots of praise, indeed. Coming
from such a background, I cannot over emphasize the long felt need for the
same.
Internet use, especially for medical education and training in India,
has increased by leaps and bounds over the last five years. In spite of
that, institutional subscriptions for journals are poor due to funding
restrictions.
Free access is helping many medical students and trainees far more
than it is probably appreciated. The approach and awareness of doctors in
training has changed in a better direction, in the light of such quick and
comprehensive access to all the recent developments in the medical world.
From my personal experience, the idea has changed medical education in a
very positive way.
It is too good to get this facility free of cost. It could be a bit better
if many of the other publishing houses (both from the United Kingdom and
United States of America) follow the example set by the BMJ group.
Yours sincerely
Dr S Chakrabarti
Senior House Officer
Dear Sir,
It is with great interest that we read the recent publication by Thomas and colleagues investigating ward-based patient care.1 They describe a study in which 28 medical students were randomised to either control (no intervention) or intervention (performance feedback and error management training) groups, performing simulated ward rounds complicated by environmental distractors. Significant reductions in errors were se...
Dear Sir,
It is with great interest that we read the recent publication by Thomas and colleagues investigating ward-based patient care.1 They describe a study in which 28 medical students were randomised to either control (no intervention) or intervention (performance feedback and error management training) groups, performing simulated ward rounds complicated by environmental distractors. Significant reductions in errors were seen in both groups from the first to the second ward round, with a significantly greater reduction seen in the intervention group.
We thoroughly commend on their efforts to add to the body of literature for what is such a crucial, but until now has been a sparsely investigated, area of care. There can be no doubt that in current practice, the conduct of ward rounds may be hugely variable,2, 3 with significant implications for patient outcomes.2 In surgical literature, the phenomenon of "failure to rescue" describes failures in ward-based management of complications, which represent a major source of variability in surgical outcomes, emphasising the need to focus on ward rounds to improve outcomes.4
Future research in this area must be robust, evidence-based, and ideally tied to clinically relevant subjects and outcomes. With this in mind, we would like to raise several questions in reference to the study by Thomas et al. How were the "distractors" selected? Loud radio noises and upset relatives would appear to represent fairly arbitrary factors with unclear relevance to clinical care. Additionally, the authors appear to suggest that the intervention included very specific feedback on how to cope with these distractors - if part of the scoring is to assess whether the radio was turned off, and the intervention includes instruction to do so, can the result be truly deemed valid? Finally, was there a reason for selecting medical students rather than a more valid population of clinical staff such as house officers, or even residents, who are commonly responsible for the ward round?
Recently, we have described the Surgical Ward-care Assessment Tool (SWAT), a checklist-based tool for technical skills, and the Ward-based Non-Technical Skills score (W-NOTECHS), a Likert-based tool for non-technical skills; together these represent objective, validated scoring scales for ward round performance.5 It is possible that the adaptation of such surgical rating scales to address other specialty populations may present an effective way forward. We are fully in agreement with Thomas and colleagues in their statement that to move ward round initiatives forward, we must in future focus on changing patient safety behaviours. Thus, future assessments of ward round performance must focus on objective assessment metrics which are generalisable across studies, contexts, and specialties. Only in this manner can reliable, reproducible interventions be developed to standardise and improve care and outcomes.
References
1. Thomas I, Nicol L, Regan L, et al. Driven to distraction: a prospective controlled study of a simulated ward round experience to improve patient safety teaching for medical students. BMJ Qual Saf 2014.
2. Pucher PH, Aggarwal R, Darzi A. Surgical ward round quality and impact on variable patient outcomes. Ann Surg 2014; 259:222-6.
3. Blucher KM, Dal Pra SE, Hogan J, Wysocki AP. Ward safety checklist in the acute surgical unit. ANZ J Surg 2013.
4. Silber JH, Williams SV, Krakauer H, Schwartz JS. Hospital and patient characteristics associated with death after surgery. A study of adverse occurrence and failure to rescue. Med Care 1992; 30:615-29.
5. Pucher PH, Aggarwal R, Srisatkunam T, Darzi A. Validation of the Simulated Ward Environment for Assessment of Ward-Based Surgical Care. Ann Surg 2014; 259:215-21.
Conflict of Interest:
Rajesh Aggarwal is a consultant for Applied Medical. No other competing interests declared.
This scholarly article has been a fine example of what a fresh
approach and interdisciplinary overview can do.
We work with illness explanatory models of patients from various
outpatient clinics who suffer from biomedically unexplained fatigue and
weakness for six months or more. Also, in private practice of clinical
psychiatry compliance is the pivotal issue. We find that cultural
epide...
This scholarly article has been a fine example of what a fresh
approach and interdisciplinary overview can do.
We work with illness explanatory models of patients from various
outpatient clinics who suffer from biomedically unexplained fatigue and
weakness for six months or more. Also, in private practice of clinical
psychiatry compliance is the pivotal issue. We find that cultural
epidemiology plays a significant role in understanding and managing
patients' compliance and outcome. Either intentional error or violation,
or unintentional slip or lapse, patients do always have subjective
explanation for their behaviour. The antecedents of compliance or non-
compliance can be found:
(1)in patient's illness experience, different
variables of which include stigma of illness or treatment, anticipated
outcome, perceived seriousness of the symptoms, and many other
sociocultural contextual factors;
(2)in subjective meaning of the illness
as exemplified by the perceived causes of the illness and their linkages
among each other; and
(3)his experiences with the help seeking behaviour
and the agencies of help, with their meeting patient's perceived needs.
Patient's explanatory models (emic) and its match or otherwise with
the explanatory models of the professional care giving agencies (etic) is
an important determinant of the patient's compliance toward the prescribed
treatment. Careful attention to the patient's emic is facilitated by
cultural epidemiological approach with the use of Explanatory Model
Interview Catalogue(EMIC), a tool that can be used in research as well as
in clinical practice. It focuses on patient's experience, meaning, and
behaviour while retaining the qualitative as well as the quantitative
aspects. Ratings on predetermined codes facilitate comparison and analysis
apart from crystallizing the salient features of the explanatory model.
Reliability of this effective tool has been documented in studies on
leprosy and depression.
The Hayes, Batalden and Goldmann piece is an important contribution
to the debate about what exactly is practice improvement. Most practice
improvement thinking is anchored in the 'innovation' paradigm, and this
paradigm is predominantly 'gadget thinking'. Others' solutions are to be
adopted here because they produce great outcomes elsewhere. Except now we
have to figure out how we can get the gadget to work.
Few commen...
The Hayes, Batalden and Goldmann piece is an important contribution
to the debate about what exactly is practice improvement. Most practice
improvement thinking is anchored in the 'innovation' paradigm, and this
paradigm is predominantly 'gadget thinking'. Others' solutions are to be
adopted here because they produce great outcomes elsewhere. Except now we
have to figure out how we can get the gadget to work.
Few commentators have been game to shift towards acknowledging that care
practices are now too complex for 'gadget thinking'. Hayes and colleagues
are an exception. They propose that frontline professionals themselves
need to become smarter at 'co-designing' solutions that suit their unique
contexts and practices. Here, we are not talking about adopting new
gadgets from elsewhere. We care talking about people who will - and who
have the skill to - take inspiration from the smartness that may be
invested in whatever gadget or improvement initiative, and apply this
smartness to their own workpractices. Indeed, these professionals may not
even need inspiration to come from elsewhere: they may well be motivated
by issues arising in their own work, and decide to redesign their
practices.
But to date, we have not focused on what this ability to co-design care
practices consists in. We expect frontline professionals to somehow know
how to co-design practice, and know how to be smart about what they do and
what they should do. And yet, their training has not skilled them in
practice design. We nevertheless expect them to readily (re)design the
organisational dimensions of their work. Usually, such designs fall prey
to people's espoused ideas and pre-existing assumptions about how things
work and should work. Often there are worrying gaps between what people
know and what they (think they) do. Put differently, smartness, in the
sense of learning about how to manage complex situations and improve
complex practices, is rare.
Smartness cannot be expected to exist or arise in situations where there
are no resources available for professionals to learn about (or 'make
explicit') the complexities of their own day-to-day work. Smartness must
be nurtured.
The way par excellence to achieve this is professionals, just as do top-
end athletes, studying their own performances. In sport, video-ing one's
game for transforming good performances into excellent ones is now not
just common but also indispensable. This is about capitalising on and
building on existing strengths. By analogy, video-ing in situ practice and
using the resulting footage to reflect on the work is central to enhancing
smartness at work. This is what Katherine Carroll and Jessica Mesman and
colleagues have referred to as 'exnovation'.
Of course, many excuses and objections are raised to auto-observation, the
most common ones of which are privacy, the Hawthorne effect, and
subpoenable evidence. But these concerns are over-stated, and they trade a
real need and opportunity for improvement and smartness off against
maintaining the status quo. Without auto-observation, existing habits and
routines will go on unquestioned. Work can only become harder, as the only
solutions to improvement will remain gadget-based. Smartness, by contrast,
starts from where we are, and explores where we can go.
Dear Editor:
I agree that every opportunity should be taken to discuss with patients with diabetes how they can reduce the risk of complications, and that screening can present one such opportunity. However, because the effectiveness of this approach has not been tested in an RCT, it was not included in the review on which this Effective Health Care Bulletin was based.
Grogan et al[1] report that their Patient Satisfaction Questionnaire (PSQ) is a valid and internally reliable tool for assessing patient satisfaction with primary care services despite the acknowledgement in their discussion that further research is required to confirm other aspects of reliability and validity. We feel that their conclusion is premature.
Having recently been involved in the valida...
To the Editor
I have recently returned from the Association of Simulated Practice in Healthcare 2014 conference in Nottingham and whilst there was privileged to hear and meet Professor Erik Hollnagel. He presented eloquently on his work relating to “From Safety I to Safety II” [1] which provided an excellent opening for the conference’s theme of “Changing Behaviours.” His work sparked much debate and reflection, part...
Dear Editor,
Roberts et al[1] provide a commentary on the Patient Satisfaction Questionnaire (PSQ) that we have developed and validated.[2][3] Whilst they accept that the PSQ is a valid and internally reliable tool for assessing patient satisfaction with primary care services, they suggest that further work is required before the measure is adopted. In particular they point to the need to assess the acceptabi...
Dear Editor,
Recently, Provenzano and colleagues found that an electronic tool collecting real-time clinical information directly from front-line providers was both feasible and useful to evaluate inpatient deaths [1]. These findings concur with our evaluation of the preventability of death using a simple electronic evaluation tool in our 46-bed adult Intensive Care Unit.
From September 2010 to Sept...
Dear Editor
The provision of free access to the electronic versions of journals to the users in the developing world deserves lots of praise, indeed. Coming from such a background, I cannot over emphasize the long felt need for the same.
Internet use, especially for medical education and training in India, has increased by leaps and bounds over the last five years. In spite of that, institutional subscr...
Dear Editor
This scholarly article has been a fine example of what a fresh approach and interdisciplinary overview can do.
We work with illness explanatory models of patients from various outpatient clinics who suffer from biomedically unexplained fatigue and weakness for six months or more. Also, in private practice of clinical psychiatry compliance is the pivotal issue. We find that cultural epide...
The Hayes, Batalden and Goldmann piece is an important contribution to the debate about what exactly is practice improvement. Most practice improvement thinking is anchored in the 'innovation' paradigm, and this paradigm is predominantly 'gadget thinking'. Others' solutions are to be adopted here because they produce great outcomes elsewhere. Except now we have to figure out how we can get the gadget to work. Few commen...
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