The article by Koppel, The health information technology safety framework: building great structures on vast voids, 11/19/15, seen at http://m.qualitysafety.bmj.com/content/early/2015/11/19/bmjqs-2015-004746.full.pdf, describes an EHR environment that violates just about every principle of safe system design. It is no wonder that there continue to be significant safety issues with EHRs.
"Most experts would agree that cornersto...
The article by Koppel, The health information technology safety framework: building great structures on vast voids, 11/19/15, seen at http://m.qualitysafety.bmj.com/content/early/2015/11/19/bmjqs-2015-004746.full.pdf, describes an EHR environment that violates just about every principle of safe system design. It is no wonder that there continue to be significant safety issues with EHRs.
"Most experts would agree that cornerstones of safety in any industry, and as pointed out in the IOM report, To Err is Human: Building a Safer Health System, and [by] many others, are simplicity, uniformity, and ease of use. Today's EHRs (of which there a hundreds of products on the market) as a whole are anything but simple, uniform and easy to use. . . . 'Requiring physicians to spend large amounts of time to operate EHR systems that are poorly designed, is a poor substitute for creating well-designed, safe, and easy-to-use EHR systems.'(1) It is stunning to me, that in a [2013] 40-minute talk on patient safety at one of the national organizations of neurosurgeons, Dr. Donald Berwick hardly mentioned HIT or the EHR."(2)
I do not believe we will effectively address the patient safety issues inherent in today's EHR environment until government, large health systems, and/or organized medicine, ideally working in concert, create a fundamental change in our approach, i.e., standardized EHRs with open source code optimally licensed and governed so that end users can lead and control innovation.
1. Hirschtick RE, Electronic Records and Hospital Progress Notes, JAMA 2012;308:2337.
2. Wilder BL, The Politics of the EHR: Why we're not where we want to be and what we need to do to get there, 10/1/13, http://www.openhealthnews.com/articles/2013/politics-ehr-why-we're-not-where-we-want-be-and-what-we-need-do-get-there. (access 12/7/15).
I commend Vermeulen et al for addressing a fundamental question: Is
ED length of stay (ED LOS), a globally used key performance indicator,
actually associated with improvement in quality of care[1]?
Vermeulen et al set out to compare whether patients presenting with
one of three acute conditions (high acuity asthma, upper
arm/forearm/shoulder fracture and acute myocardial infarct) at hosp...
I commend Vermeulen et al for addressing a fundamental question: Is
ED length of stay (ED LOS), a globally used key performance indicator,
actually associated with improvement in quality of care[1]?
Vermeulen et al set out to compare whether patients presenting with
one of three acute conditions (high acuity asthma, upper
arm/forearm/shoulder fracture and acute myocardial infarct) at hospitals
with reduced ED LOS following the introduction of the Ontario Emergency
Room Wait time strategy were also likely to experience improvements in
other measures of quality of care; i.e. is evidence based treatment more
likely given and if so, is it done in a timely fashion [1]?
Interestingly, the study did not reveal an association between
reduced ED LOS and improvement of other quality indicators, surprisingly
not even for measures involving timely delivery of care [1]. Nevertheless,
they did find that shift-level crowding is inversely associated with
quality indicators related to timeliness of care: timeliness of
reperfusion in AMI, splinting and analgesia in adult patients with
fractures and steroid, bronchodilator within 60 minutes of presentation
with acute asthma[1]. This supports prior studies reporting a correlation
between ED crowding and increased short-term or in patient mortality [2,
3] and failure to administer timely care [4]. In my view, this study
confirms that both quality initiatives and assessment of quality of care
ought to be multidimensional and not focussed on one quality indicator.
The association with shift-level crowding emphasises that we must
concentrate on mapping trends in ED crowding over time to allow for
appropriate ED staffing and institute systems that aid efficiency while
assuring safety during those times. This may prove to be a more effective
system to improve overall quality of care that encompasses safety,
efficiency, timeliness and patient centredness [5] rather than focussing
on reducing ED LOS in isolation, which appears to be a poor measure of
quality of care[1]. Furthermore, reducing ED LOS equals time pressure, a
known major contributing factor to error in human performance, which is
likely to predominantly affect the diagnosis and treatment in complex
patients due to performance degradation[6]. Finally, though it seems
obvious that reduced ED LOS improves patient satisfaction, if it is
associated with abrupt staff and contributes to human error[6], this is
unlikely to be the case. I applaud Vermeulen et al for highlighting the
critical issue with using one-dimensional measures to assess quality of
healthcare.
Word count: 394.
References.
1. Vermeulen, M.J., et al., Are reductions in emergency department
length of stay associated with improvements in quality of care? A
difference-in-differences analysis. BMJ Qual Saf, 2015.
2. Guttmann, A., M.J. Schull, and M.J. Vermeulen, Association between
waiting times and short term mortality and hospital admission after
departure from emergency department: population based cohort study from
Ontario, Canada. BMJ, 2011. 342.
3. Sun, B., R. Hsia, and R. Weiss, Effect of emergency department crowding
on outcomes of admitted patients. Ann Emerg Med, 2013. 61: p. 605-611.
4. Pines, J., J. Hollander, and A. Localio, The association between
emergency department crowding and hospital performance on antibiotic
timing for pneumonia and percutaneous intervention for myocardial
infarction. Acad Emerg Med, 2006. 13: p. 873-878.
5. Pronovost, P., et al., How can clinicians measure safety and quality in
acute care? Lancet, 2004. 363: p. 1061-1067.
6. Suzuki, T., T.L. Von Thaden, and W. Geibel Influence of time pressure
on aircraft maintenance errors. 2008.
The paper by Sikka, Morath and Leape is spot on (1). The authors call
for adding a fourth aim to the Triple Aim: improving the experience of
those providing care--physicians, nurses and others. This builds on our
previous work "From Triple to Quadruple Aim: Care of the Patient Requires
Care of the Providers" in which we make a similar recommendation (2).
We also agree with the importance of creating conditions w...
The paper by Sikka, Morath and Leape is spot on (1). The authors call
for adding a fourth aim to the Triple Aim: improving the experience of
those providing care--physicians, nurses and others. This builds on our
previous work "From Triple to Quadruple Aim: Care of the Patient Requires
Care of the Providers" in which we make a similar recommendation (2).
We also agree with the importance of creating conditions where
healthcare workers can thrive, and find meaning and joy in their work
(3,4, 5).
Widespread physician and other health professional dissatisfaction
can be taken as an early warning sign of dysfunction within the healthcare
system. At present many front line clinicians experience a toxic
environment, with near-constant multi-tasking, heavy documentation
burdens, frequently shifting performance measures, high cognitive
workloads and what is often perceived to be oppressive regulatory
micromanagement.
Remedying the widespread burnout among physicians and other health
professionals will require empathy, sympathy and compassion for those on
the front lines of care, and directing efforts to the intrinsic motivation
and professionalism of the workforce.
For healthcare organizations we recommend regularly measuring and
improving workforce well-being, making this a vital measure on an
institution's data dashboard. For policy makers we recommend evidenced-
based regulation, coupled with studies demonstrating the time-costs of
compliance. For technology vendors we recommend the humility to understand
clinicians' workflow and incorporate human factors, efficiency and the
ability of clinicians to maintain relationship with patients into design.
For payers we recommend payment models that align with the values and
goals of the healthcare system, and the documentation for which are
minimized and manageable. For all stakeholders, before a new expectation
is established, we recommend asking: What will busy clinicians forego to
manage this new requirement?
Well-being of the healthcare workforce is a shared responsibility. As
part of that shared responsibility, we have contributed to a set of on-
line, free, interactive practice transformation resources designed to help
physicians and their practices increase efficiency, improve the quality of
care, strengthen relationships and thereby increase joy in the practice of
medicine. (6)
References
1. Sikka R, Morath JM, Leape L. The quadruple aim: care, health, cost
and meaning in work. BMJ Qual Saf. Published on line
http://qualitysafety.bmj.com/content/early/2015/06/02/bmjqs-2015-
004160.full.pdf+html
2. Bodenheimer T, Sinsky CA. From triple to quadruple aim: care of the
patient requires care of the provider. Ann Fam Med 2014;12:573-576.
3. Sinsky CA, Willard R, Schutzbank AM, Sinsky TA, Margolius D,
Bodenheimer T. In search of joy in practice: a report of 23 high-
functioning primary care practices. Ann Fam Med 2013;11:272-278
4. Lucien Leap Institute. The National Patient Safety Foundation. Through
the eyes of the workforce: creating joy, meaning, and safer health care.
2013
5. Wallace, Jean E et al. Physician wellness: a missing quality indicator.
The Lancet , Volume 374 , Issue 9702 , 1714 - 1721
6. www.stepsforward.org
I was interested to read the thoughtful article by Imogen Mitchell
and colleagues, echoing longstanding criticisms by Kaveh Shojania, Charles
Vincent and others on the low value of high volume incident reporting.
There is little learning from categorical data, repeated many times,
around falls or minor medication errors. However, there was a time at the
National Patient Safety Agency, where we experimented with a
multi...
I was interested to read the thoughtful article by Imogen Mitchell
and colleagues, echoing longstanding criticisms by Kaveh Shojania, Charles
Vincent and others on the low value of high volume incident reporting.
There is little learning from categorical data, repeated many times,
around falls or minor medication errors. However, there was a time at the
National Patient Safety Agency, where we experimented with a
multidisciplinary meeting to make sense of reports, screened by skilled
clinical reviewers. We concentrated on the freetext - the `story' of the
incident. These weekly meetings became a dynamic and illuminating
discussion of problem and solutions, with fiercely contested accounts from
differing perspectives (surgeon, theatre nurse, GP, human factors or
design experts). This space for reflective learning (Lamont 2011)reached
places that desk-based data analysis couldn't go. The key was in the
quality of the clinical reviewers, the range of clincal and safety
expertise at the weekly meetings and a national function with ability to
act on the risks, once articulated in this forum. It would be a shame to
lose this potential for learning from a few carefully selected incidents,
with the right analytic and sense-making skills and resources, in
justified criticism of the limited safety gains to date from large
incident reporting systems.
Tara Lamont
Deputy Director
NIHR Dissemination Centre
Lamont Tara. "Re-cognising" risks: from space shuttles to chest
drains BMJ 2011; 343 :d4393
Conflict of Interest:
I worked at the National Patient Safety Agency 2004-2011.
Mitchell, Schuster, Smith et al (1) present the results of semi-structured interviews with 11 international patient safety experts, 15 years after publication of the US Institute of Medicine's landmark report 'To Err Is Human'.(2) One of the Institute's recommendations was the introduction of healthcare incident reporting.
Qualitative analysis of the interviews by Mitchel...
Mitchell, Schuster, Smith et al (1) present the results of semi-structured interviews with 11 international patient safety experts, 15 years after publication of the US Institute of Medicine's landmark report 'To Err Is Human'.(2) One of the Institute's recommendations was the introduction of healthcare incident reporting.
Qualitative analysis of the interviews by Mitchell et al identified 5 problems - sheer volume of reports received and inadequate report processing, lack of involvement by medical practitioners, insufficient response and feedback to reports, inadequate funding and organizational backing, and failure to use electronic records. The article stated that the interviewees noted little progress in utilizing adverse event information to positively influence patient outcome - a sobering finding.
In drawing on the opinion and experience of these national and international experts, maybe we are missing critical elements essential for utilization of incident reports. Their perspective and experience of incident reporting may have diluted or lost the value of this activity at the local healthcare facility. Taking anaesthesia as my example, reporting of adverse events and 'near misses' functions most robustly in the local department setting, where regular morbidity and mortality meetings allow free discussion of events in a 'no blame' culture. Knowledge of working conditions, staffing levels, rosters and surgical capabilities allows useful input regarding system factors involved in the incident, human factor analysis, and provision of feedback to people and the institution, in a timely fashion. Discussion of adverse events is a learning experience for everyone involved. The costs incurred by a department in the process of incident submission, analysis, discussion and feedback is minimal, as it is part of the contracted and expected duties of anaesthetic consultants and trainees. Trainees have evidence of reporting leading directly to tangible action, as closing the loop with feedback occurs soon after the incident. Anaesthesia incident reporting has become embedded in the functioning of my specialty at a departmental level, because it has addressed the identified problems - thus doctors do report, the data collected is processed, and feedback is provided in a timely fashion, the heads of department support and facilitate morbidity and mortality reporting, and minimal costs are incurred. Electronic record usage is utilised in some departments and will enhance audit and review when more readily available. Trainees are shown that safety and quality, with incident reporting, are integral parts of everyday practice, not an added extra, or afterthought.
It is important that statewide and national reporting systems [Australian examples are Victorian Consultative Council on Anaesthetic Mortality and Morbidity (3), web-based reporting systems such as webAIRS (4)] are established, to identify patterns of failures or worrying trends in care, and recommend changes in practice. However, the considerable time-lag between adverse event occurrence, and their de-identified analysis and recommendations may reduce the impact of findings. The 5 problems identified by the interviewees are seen with these larger investigative bodies.
Incident reporting is an essential part of health safety culture and climate (5), but to reap the benefits of the essential analysis and feedback components, I advocate decentralizing the process to craft groups and hospital departments. The manageable volume of reports, increased medical involvement, and feedback loops possible with smaller units would enhance learning and quality improvement.
There is much to learn from incident reporting - we must not be buried under the pile of reports. We need to act locally, in our departments, our wards, our units, to promote and demand the collection of good data. We must provide the analysis and facilitate discussion of reports, and have safer and better quality care result from the feedback given.
References
1. Mitchell I, Schuster A, Smith K et al. Patient safety incident reporting: a qualitative study of thoughts and perceptions of experts 15 years after 'To Err is Human'. BMJ Quality and Safety Published Online First: 12th August 2015 doi:10.1136/bmjqs-2015-004405 Accessed 22nd August 2015
2. Kohn L, Corrigan J, Donaldson M. To err is human: building a safer health system. Washington, DC. National Academy Press 2000.
3. http://www.health.vic.gov.au/vccamm
4. webAIRS: https://www.anztadc.net [Internet]: Accessed 7th September 2015
5. Benn J, Koutantji M, Wallace L et al. Feedback from incident reporting: information and action to improve patient safety. Qual Saf Health Care 2009;18(1):11-21
Vermeulen et al [1] provides further insight into the effect of
emergency department (ED) crowding and length of stay (LOS) on several
quality indicators. This piece of work not only adds to the body of
literature which suggests ED crowding delays timeliness of interventions,
but importantly highlights that government initiatives targeting LOS alone
are not enough to enhance other aspects of true, q...
Vermeulen et al [1] provides further insight into the effect of
emergency department (ED) crowding and length of stay (LOS) on several
quality indicators. This piece of work not only adds to the body of
literature which suggests ED crowding delays timeliness of interventions,
but importantly highlights that government initiatives targeting LOS alone
are not enough to enhance other aspects of true, quality care delivery.
Donabedian [2] originally explored the various dimensions of quality,
using a measurement framework recognising structural, procedural and
outcome indicators. These have since been refined by various authors but
are widely recognised to include efficacy, access, efficiency, safety,
equitability, appropriateness and acceptability - the full spectrum of
which must be considered when assessing the quality of care in emergency
departments and hospitals.
Like the Ontario ER Wait Time Strategy, Australia has adopted a
National Emergency Access Target (NEAT) as a way of addressing crowding,
patient flow and access to emergency care. Overcrowding and prolonged LOS
in ED for admitted patients is certainly associated with poorer outcomes,
and the introduction of a 4-hour rule can reduce hospital mortality [3].
As is well demonstrated by Vermeulen et al, LOS targets measure when
you arrive and when you leave ED - nothing in between. While seen as a
quality access target, it in no way measures what actually happens within
this time gap. Extended wait times for medical assessment and intervention
have been associated with higher mortality rates and hospital admissions
[4], but this only looks at one part of the patient's overall emergency
experience. So although it is acknowledged that access is important,
having LOS targets may also create unintended, negative consequences. ED
doctors have less time to spend with complex patients, potentially
resulting in diagnostic error and avoidable admissions. The results of
this study show a lack of improvement in most quality indicators measured,
suggesting that perhaps purely targeting LOS can in fact compromise
effectiveness. The push to get patients through the system faster has also
resulted in sick patients being transferred to ill-equipped medical
assessment units - this I have experienced first-hand.
Quality of care is of upmost importance but is complex and difficult
to measure. Performance indicators such as NEAT are easily monitored but
are, at best, only surrogate markers of quality. As Vermeulen highlights,
strategies aimed at reducing ED LOS do not necessarily result in
improvements to the other dimensions of excellent care provision. Whilst
no detrimental effects to safety are demonstrated in this research, other
measures such as adverse events, medication errors or changes in hospital
admission rates were not captured to support this conclusion.
LOS targets may have been an appropriate first step to tackle the
issue of crowding, but there is now a need to look deeper into the quality
of care being delivered in our ED's. Interestingly, the UK has lowered its
performance threshold on the 4 hour rule, now placing emphasis on a number
of other quality indicators [5]. Quality of patient care must be
prioritised while ensuring access is maintained. This requires more
sophisticated measurements of the quality of emergency medical care.
Tess Baker
References:
1. Vermeulen MJ, Guttmann A, Stukel TA, Kachra A, Sivilotti M, Rowe BH et
al. Are reductions in emergency department length of stay associated with
improvements in quality of care? A difference-in-difference analysis. BMJ
Qual Saf 2015;0:1-10
2. Donabedian A. The quality of care. How can it be assessed? JAMA
1988; 260(12):1743-1748
3. Sprivulis PC, Da Silva JA, Jacobs IG, Frazer AR, Jelinek GA. The
association between hospital overcrowding and mortality among patients
admitted via Western Australian emergency departments. MJA 2006, 184;208-
212
4. Guttmann A, Schull MJ, Vermeulen MJ, Stukel TA. Association
between waiting times and short term mortality and hospital admission
after departure from emergency department: population based cohort study
from Ontario, Canada. BMJ 2011;342:D2983
5. Department of Health. Accident and emergency provisional quality
indicators [internet] UK: Department of Health; August 2010 [cited 2015
Sept 7]. Available from https://www.gov.uk/government/news/accident-and-
emergency-provisional-quality-indicators
This study focused on the lack of standardization for human factors
content in postgraduate training curricula. The authors emphasized the
importance of non-technical skills (NTS) such as leadership, decision
making, team working and resource management during training, highlighting
that a significant proportion of errors are based on failures of NTS as
opposed to just knowledge and technical errors. The curricula of medi...
This study focused on the lack of standardization for human factors
content in postgraduate training curricula. The authors emphasized the
importance of non-technical skills (NTS) such as leadership, decision
making, team working and resource management during training, highlighting
that a significant proportion of errors are based on failures of NTS as
opposed to just knowledge and technical errors. The curricula of medical,
surgical and critical care specialties (CCS) were analyzed for non-
technical skills, situational awareness and human factors as well as
additional terms under the headings task management, team working, and
decision making. The authors concluded that non-technical skill terms
occurred infrequently on the whole with the main occurrences in critical
care specialties. These specialties were in addition the only ones that
specified requirements for formal training in NTS. Overall non critical
care specialties lacked specific detail on learning objectives and
assessment strategies.
As of 2013 exiting UK medical students are now expected to
demonstrate situational based attributes of a foundation doctor allied to
professionalism, coping with pressure, communication, patient focus and
team working as part of the situational judgement test (1). After its
introduction, a total of 7770 applicants were asked to provide their
reactions to the SJT. Only 52.5 % concluded that the content seemed
relevant to what they thought the role of a foundation doctor should be
(vs 57.1 % in 2014 and 56.5 % in 2015) (2, 3, 4). 38.6 % agreed or
strongly agreed that the content of the SJT appeared to be fair to the
foundation programme (vs 40.4 % in 2014 and 40.6 % in 2015), with 25.4 %
applicants agreeing or strongly agreeing that the results of the SJT could
help selectors to differentiate between weaker and stronger applicants (vs
26.1 % in 2014 and 26.3 % in 2015) (2, 3, 4). At present, there is a lack
of longitudinal research studies evaluating the extent to which SJTs
effectively predict performance throughout the medical education pathway,
from medical school admissions through to independent clinical practice,
and beyond (5). This is relevant given evidence that SJTs have different
predictive validity at different stages during medical education, training
and practice (5).
The study authors highlighted that NTS training impacts patient
safety in a wide range of clinical domains, but NTS based learning
objectives feature rarely outside CCS. They argue that curricula in
general are designed with assumed NTS acquisition in a non-formalized
fashion and call for NTS to feature explicitly in all curricula and to be
assessed accordingly. I wholeheartedly agree. It is important to note that
despite initial measures to assess situational judgement robust evidence
for its actual value is lacking. We need to be certain therefore that
testing is adequate with measures that are appropriate in order to ensure
long term valuable outcomes.
Dr Neel Sharma
1. UKFPO. Situational Judgement Test 2015; Available from:
http://www.foundationprogramme.nhs.uk/pages/medical-students/SJT-EPM.
2. Patterson, F. Analysis of the Situational Judgement
Test for Selection to the Foundation Programme 2013. 2013; Available from:
http://www.isfp.org.uk/SiteCollectionDocuments/FY1-SJT-2013-Technical-
Report-May-2013-updated-for-publication.pdf.
3. Patterson, F. Analysis of the Situational Judgement
Test for Selection to the Foundation Programme 2014. 2014; Available from:
http://www.isfp.org.uk/SiteCollectionDocuments/FY1-SJT-2014-Technical-
Report-June-2014.pdf.
4. Patterson, F. Analysis of the Situational Judgement
Test for Selection to the Foundation Programme 2015. 2015; Available from:
http://www.isfp.org.uk/SiteCollectionDocuments/FY1-SJT-2015-Technical-
Report.pdf.
5. Patterson F et al. Situational judgement tests in
medical education and training: Research, theory and practice: AMEE Guide
No. 100. Medical Teacher 2015 1-15.
One example of our almost universal, daily inflicting of emotional
harm on patients is our mis-labeling of the patient's presenting problem
as the 'Chief Complaint'.
Years ago, an ICU patient said plaintively, "I'm not a complainer."
after a bedside presentation is which that is just what he was called.
Let's call it the 'Presenting Problem'--in our talk and in our notes.
It might contribute to a clima...
One example of our almost universal, daily inflicting of emotional
harm on patients is our mis-labeling of the patient's presenting problem
as the 'Chief Complaint'.
Years ago, an ICU patient said plaintively, "I'm not a complainer."
after a bedside presentation is which that is just what he was called.
Let's call it the 'Presenting Problem'--in our talk and in our notes.
It might contribute to a climate in which extreme cases become more rare.
And perhaps we could eliminate these into the bargain:
"The patient has failed multiple therapies." (when it is the therapies
that failed)
"The patient is a poor historian." (when the physician is meant to be the
historian)
"The patient admits/denies. . . "
Marshall et al's (2014) paper was highlighted as an exemplar of
stakeholder participation by a speaker at a recent public health research
conference, held in Newcastle. Participants gave useful feedback about
many of the core issues raised, which we reflect here.
Marshal et al's (2014) 'Researcher in Residence' models are suggested
as a means of co-engaging academics and practitioners in the promotion of
evide...
Marshall et al's (2014) paper was highlighted as an exemplar of
stakeholder participation by a speaker at a recent public health research
conference, held in Newcastle. Participants gave useful feedback about
many of the core issues raised, which we reflect here.
Marshal et al's (2014) 'Researcher in Residence' models are suggested
as a means of co-engaging academics and practitioners in the promotion of
evidence-informed service improvement. But participants at our event
raised questions about public involvement as key stakeholders from earlier
on in the research process. In the experience of our presenters and
participants, research that starts from questions derived from both
academics and participants (i.e. that is co-produced) is more likely to
address patient needs than questions driven by academics, funders or
institutions.
Important (though hardly novel) questions remain. Are academics open
enough to co-produced research ideas? Is there sufficient willingness to
see questions differently, to work differently, and to enable tacit
knowledge and patient and public experience to be valued as a legitimate
contribution to the research process? Public stakeholders at our event
expressed hunger to know how to engage with academia, but felt the
opportunities to do so were unclear. There is much to learn from Patient
and Public Involvement (PPI) in research.
As others have observed, effective patient and public involvement
(PPI) requires difficult conversations about vested interests (Greenhalgh
et al 2014) and power and status among stakeholders (Centre for Social
Justice 2012). Discussions about paying research participants can present
thorny issues for some, among wider concerns around how public views are
sought/used/valued/acknowledged. PPI raises philosophical questions
around 'independent research' and what this means, as well as similarly
tricky issues around what expertise and experience 'counts' (for
researchers and the public) and how to address institutional barriers and
facilitators to its use.
Public health, classically defined as 'organised community effort' to
prevent disease, prolong life and promote health (Winslow 1920 cited in
Lang and Raynor BMJ 2012), presents a unique set of challenges. The
relocation of public health responsibilities to local government raises
questions about the different cultures of research and evidence use, the
place of public involvement and democratic accountability, and how to use
opportunities to address the social determinants of health. The exemplars
used by Marshall et al (2014) are all drawn from clinical settings, and
models of PPI may need adapting for use in public health.
Our event showcased pockets of good practice and highlighted
different methods to involve patients and the public, including in public
health (see www.fuse.ac.uk). Some of these have been published elsewhere
(Centre for Social Justice 2012, Lewis and Russell 2014). Taken together
with feedback from those with experience of PPI, we can discern some
underlying principles to guide meaningful PPI in research (which may also
support research use in practice). Though not comprehensive, these include
the need to; clarify motives; reach out to marginalised groups; use
existing networks; take account of context; be reflexive and adaptive;
value different forms of knowledge and expertise; be committed to the
possibilities of facilitating change.
Neither in public health nor clinical settings have we 'cracked it'
in terms of PPI. Our conference opened a black box of similarities and
contrasts between PPI in public health and clinical settings - requiring
different approaches. Learning opportunities can flow in both directions,
recognising the complexity inherent in PPI in population health
interventions (Best et al 2009).
The researcher in residence model introduced by Marshall et al (2014)
is one approach to co-production. However, we argue that early
involvement in setting research agendas is more likely to meet the needs
of the public. There are critical blocks to effective engagement, for
example silo thinking, the "paradigm shift" (Hunter 2009) required in
academia, and specific skills amongst researchers. New ways of doing
research must have co-production at their core - they must be
collaborative and engage stakeholders from the start of the research
process, when questions are being formulated, through to dissemination.
References
Best, A., Terpstra, J.L., Moor, G. Riley, B., Norman, C.D., Glasgow, R.E.
(2009) Building knowledge integration systems for evidence-informed
decisions Journal of Health Organization and Management, Vol. 23, issue 6,
pp 627 - 641.
Centre for Social Justice and Community Action, Durham University and
the National Co-ordinating Centre for Public Engagement (2012) Community-
based participatory research. A guide to ethical principles and practice,
available from www.publicengagement.ac.uk
Hunter, D. J. (2009) Leading for Health and Wellbeing: the need for a
new paradigm Journal of Public Health, Volume 31, No. 2, pp 202-204
Lang, T and Raynor, G (2012) Ecological public health: the 21st
century's big idea? British Medical Journal 345: e5466. 21 August.
Lewis and Russell (2011) Being embedded: A way forward for
ethnographic research Ethnography 2011 12: 398. DOI:
10.1177/1466138110393786
Lomas, J (2007) the in-between world of knowledge brokering British
Medical Journal, 334, (7585): 129.
Conflict of Interest:
All authors were members of the organising committee for Beyond tokenism: PPI with impact
Enriching patient and public involvement in public health research, October 16th 2014. The event was sponsored by the Newcastle Institute of Social Renewal, Newcastle University Faculty of Medical Science, Fuse Centre for Translational Research in Public Health and Involve North East.
We read with interest your Editorial re the role of families in
preventing avoidable harm in children (1).
Many public hospitals in Queensland Health in Australia have now
implemented Ryan's Rule. When Ryan's parents were worried he was getting
worse they didn't feel their concerns were acted upon in time. It was
subsequently established that Ryan died from likely preventable causes.
Ry...
We read with interest your Editorial re the role of families in
preventing avoidable harm in children (1).
Many public hospitals in Queensland Health in Australia have now
implemented Ryan's Rule. When Ryan's parents were worried he was getting
worse they didn't feel their concerns were acted upon in time. It was
subsequently established that Ryan died from likely preventable causes.
Ryan's Rule was developed to provide patients of any age, families and
carers with another way to get help. Families and carers are educated by
staff and with the prominent display in the wards of Ryan's Rule posters
containing the following advice re escalation.
There are three steps for families and carers to raise their
concerns:
[1] talk to a nurse or doctor about your concerns. If you are not
satisfied with the response->
[2] Talk to the nurse in charge of the shift. If you are not
satisfied with the response ->
[3] Phone 13 Health (13 43 25 84) or ask a nurse to call on your
behalf. Request a Ryan's Rule Clinical Review and provide information
about hospital name, patient's name. ward, bed number, your conduct
number.
A Ryan's Rule nurse or doctor will review the patient and assist.
We await with interest the results of the prospective audit of this
statewide process.
Yours sincerely,
Dr Mai-Ing Koh MBBS (JCU), Resident, Namboru Hospital
Assoc Prof Tieh Hee Hai Guan Koh BA MA (Oxon) MBBChir(Cantab) MD
(Cantab) FRCPCJ
Director Neonatology The Townsville Hospital
Queensland 4814
AUSTRALIA
1) Roland, D. But I told you she was ill! The role of families in
preventing avoidable harm in children
BMJ Qual. Saf. 2015 24:186-187
Dear Editor,
I commend Vermeulen et al for addressing a fundamental question: Is ED length of stay (ED LOS), a globally used key performance indicator, actually associated with improvement in quality of care[1]?
Vermeulen et al set out to compare whether patients presenting with one of three acute conditions (high acuity asthma, upper arm/forearm/shoulder fracture and acute myocardial infarct) at hosp...
The paper by Sikka, Morath and Leape is spot on (1). The authors call for adding a fourth aim to the Triple Aim: improving the experience of those providing care--physicians, nurses and others. This builds on our previous work "From Triple to Quadruple Aim: Care of the Patient Requires Care of the Providers" in which we make a similar recommendation (2).
We also agree with the importance of creating conditions w...
I was interested to read the thoughtful article by Imogen Mitchell and colleagues, echoing longstanding criticisms by Kaveh Shojania, Charles Vincent and others on the low value of high volume incident reporting. There is little learning from categorical data, repeated many times, around falls or minor medication errors. However, there was a time at the National Patient Safety Agency, where we experimented with a multi...
The Editor, BMJ Quality and Safety,
Mitchell, Schuster, Smith et al (1) present the results of semi-structured interviews with 11 international patient safety experts, 15 years after publication of the US Institute of Medicine's landmark report 'To Err Is Human'.(2) One of the Institute's recommendations was the introduction of healthcare incident reporting.
Qualitative analysis of the interviews by Mitchel...
Dear Editor,
Vermeulen et al [1] provides further insight into the effect of emergency department (ED) crowding and length of stay (LOS) on several quality indicators. This piece of work not only adds to the body of literature which suggests ED crowding delays timeliness of interventions, but importantly highlights that government initiatives targeting LOS alone are not enough to enhance other aspects of true, q...
This study focused on the lack of standardization for human factors content in postgraduate training curricula. The authors emphasized the importance of non-technical skills (NTS) such as leadership, decision making, team working and resource management during training, highlighting that a significant proportion of errors are based on failures of NTS as opposed to just knowledge and technical errors. The curricula of medi...
One example of our almost universal, daily inflicting of emotional harm on patients is our mis-labeling of the patient's presenting problem as the 'Chief Complaint'.
Years ago, an ICU patient said plaintively, "I'm not a complainer." after a bedside presentation is which that is just what he was called.
Let's call it the 'Presenting Problem'--in our talk and in our notes. It might contribute to a clima...
Marshall et al's (2014) paper was highlighted as an exemplar of stakeholder participation by a speaker at a recent public health research conference, held in Newcastle. Participants gave useful feedback about many of the core issues raised, which we reflect here.
Marshal et al's (2014) 'Researcher in Residence' models are suggested as a means of co-engaging academics and practitioners in the promotion of evide...
Dear Editor,
We read with interest your Editorial re the role of families in preventing avoidable harm in children (1).
Many public hospitals in Queensland Health in Australia have now implemented Ryan's Rule. When Ryan's parents were worried he was getting worse they didn't feel their concerns were acted upon in time. It was subsequently established that Ryan died from likely preventable causes. Ry...
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