Adding the element of safety to medical education can not be effected
unless the institutions supplement their systems with program of outcomes
assesment.
While all that Dr Stevens describes is of interest, only when it is
established that the medical safety material that has been presented is
absorbed and put into practice will the validity of the suggestions be
established.
Adding the element of safety to medical education can not be effected
unless the institutions supplement their systems with program of outcomes
assesment.
While all that Dr Stevens describes is of interest, only when it is
established that the medical safety material that has been presented is
absorbed and put into practice will the validity of the suggestions be
established.
This requires testing of competence at completion of the program and
evaluation of performance,with remediation as required, thereafter.
We thank Dr. Iedema for highlighting that a gap exists in providers
having the skillset to 'work smarter.' We agree that novel approaches to
healthcare improvement are required that move beyond gadget-based
solutions and that require a new set of skills of providers and provider
organizations. The suggestion of video taping one's performance to review
how the system (and its participants) currently operates and reflect...
We thank Dr. Iedema for highlighting that a gap exists in providers
having the skillset to 'work smarter.' We agree that novel approaches to
healthcare improvement are required that move beyond gadget-based
solutions and that require a new set of skills of providers and provider
organizations. The suggestion of video taping one's performance to review
how the system (and its participants) currently operates and reflect on
how to (re-) design their workflows is intriguing. It exemplifies the
concept of 'exnovation' or 'innovation from within', meaning innovation
arises from within established practice, and from within practitioners.
However, our article did not aim to imply that it is providers who
are responsible for, or required to gain the skills to work smarter. Our
message is directed to all those seeking and driving healthcare system
improvement. Although we agree that providers may benefit from the
skillsets that Dr. Iedema proposed, we believe that those seeking change
also need additional skillsets and perspectives. We can no longer presume
that healthcare providers have the space to add new tasks, workflows,
procedures etc. We have, as a system, to work on simplifying the current
work environment, finding non-value added tasks and work with healthcare
providers to design ways of achieving improved outcomes that don't add net
new workload or complexity. Now some may argue that added work at one
part of the system may have larger benefits downstream. This may be true
but those charged with carrying the weight of the new tasks have to do so
in a sustainable and reliable way. Otherwise subsequent change
initiatives will disrupt this balance and its downstream benefits.
Our message was also aimed at those adding new regulation, policies,
performance measures and incentives or disincentives. Adding pressure on
top of an environment that doesn't have the space nor the knowledge and
skill to create it only adds to workplace burden, resistance and non-
sustained improvement. We believe that there needs to be a system-wide
look at the capabilities and investments required to create a 'working
smarter' healthcare system. Providers will play their role but they need
a commitment that a 'work harder' strategy is no longer acceptable.
I will call the work of giving Medicine to poor countries, a Great English
men do this beautiful things. From a Professor of internal medicine -
Jorge H Jimenez.
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
As a member of the professional organisation for nurses in Ontario, I
would like to direct nurses and other interested readers to the web page
of the Registered Nurses Association of Ontario, www.rnao.org
This site has a wealth of position statements, policies, submissions
to a variety of health stakeholders and other documents relating to
providing...
As a member of the professional organisation for nurses in Ontario, I
would like to direct nurses and other interested readers to the web page
of the Registered Nurses Association of Ontario, www.rnao.org
This site has a wealth of position statements, policies, submissions
to a variety of health stakeholders and other documents relating to
providing quality health care as well as nursing.
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.
I very much agree with the authors concerning the role of Risk
Management in the Patient Safety arena. In fact, as a Director of Risk
Managment in an integrated delivery system in Dayton, Ohio, I have been
very involved in the patient safety efforts of our two acute care
organizations, as well as the other entities within our system. My
concern for the past few months has been how to best focus the ri...
I very much agree with the authors concerning the role of Risk
Management in the Patient Safety arena. In fact, as a Director of Risk
Managment in an integrated delivery system in Dayton, Ohio, I have been
very involved in the patient safety efforts of our two acute care
organizations, as well as the other entities within our system. My
concern for the past few months has been how to best focus the risk
manager role with safety. It is virtually impossible for the risk manager
to be involved at the level that I would like to see, and still maintain
all the other functions of a professional risk manager, ie; insurance
renewal, claims management, etc. We are struggling with reorganization in
our department and the authors have greatly assisted me in my belief that
we need to chart a new future and not stand on the sidelines when safety
initiatives are proposed. We also need not to feel guilty as Risk
Managers if our role is not the model that we have been traditionally
taught!
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. . . "
I share much of Dr Morris' enthusiasm for decision support. While
involved in an evaluation of a decision support targeting vancomycin
ordering practice,[1] I had the opportunity to observe the potential
impact of this approach. However, as a clinician using the same
computerized order entry system in daily practice, I also recognized the
major limitation of this approach: users will not tolerate many...
I share much of Dr Morris' enthusiasm for decision support. While
involved in an evaluation of a decision support targeting vancomycin
ordering practice,[1] I had the opportunity to observe the potential
impact of this approach. However, as a clinician using the same
computerized order entry system in daily practice, I also recognized the
major limitation of this approach: users will not tolerate many such
interventions at any given time.
Too many alarms can contribute to a sense of general noise, so that
they lose their value.[2] Similarly, too many triggers for guidelines, or
even alerts such as potential drug-drug interactions, will result in users
clicking past all such screens, so that in the end, none of the screens
will work. Forcing users to follow a given guideline or respond to a
particular alert runs the risk of adding an intolerable time burden to
frequent users of the system – e.g., interns and residents who write
multiple orders a day.
Consider the admission orders for even a routine medical admission.
Possible guidelines might relate to many medications (e.g., choices of
antibiotics), diagnostic orders ('does this patient really need a KUB –
the yield of plain abdominal radiographs is known to be low in most
clinical situations'[3]), various prophylactic strategies (“do you want to
order DVT prophylaxis?' '...stress ulcer prophylaxis?' etc.)
Elderly patients will trigger even more guidelines - does the patient
need fall precautions? How about a soft matteress or other decubitus ulcer
precautions? Pneumococcal vaccination prior to discharge?[4] Vlu vaccine?
[4] Does the patient have an advanced directive?[5]
The list goes on, and this does not even include guidelines triggered
by specific admitting diagnoses e.g., guidelines for treatment of
community acquired pneumonia, acute coronary syndrome, hip fracture,
gastrointestinal bleeding, stroke, etc. etc, not to mention important
secondary diagnoses – 'This patient has diabetes: do you want to add an
angiotensin converting enzyme inhibitor.' 'This patient has a diagnosis of
congestive heart failure, but there is no record of an echocardiogram or
other assessment of ejection fraction.' 'This patient is on prednisone;
would you like to add a bisphosphonate to protect against osteoporosis?'
Thus, computerized systems offer a greater chance of success for
implementation of a single guideline, it is unlikely that this benefit
will generalize to more than a handful of such protocols at any given
time. Further research will need determine optimal strategies for
harnessing the potential of computerized decision support. Currently,
though, it is unrealistic to think that an institution acquiring an order
entry system could expect to impact practice in more than a few areas
using this approach.
References
(1) Shojania KG, Yokoe D, Platt R, Fiskio J, Ma'luf N, Bates DW.
Reducing vancomycin use utilizing a computer guideline: results of a
randomized controlled trial. J Am Med Inform Assoc 1998;5:554-562.
(2) Cropp AJ, Woods LA, Raney D, Bredle DL. Name that tone. The
proliferation of alarms in the intensive care unit. Chest 1994;105:1217-
1220.
(3) Harpole LH, Khorasani R, Fiskio J, Kuperman GJ, Bates DW.
Automated evidence-based critiquing of orders for abdominal radiographs:
impact on utilization and appropriateness. J Am Med Inform Assoc
1997;4:511-521.
(4) Dexter PR, Perkins S, Overhage JM, Maharry K, Kohler RB, McDonald
CJ. A computerized reminder system to increase the use of preventive care
for hospitalized patients. N Engl J Med 2001;345:965-970.
(5) Heffner JE, Barbieri C, Fracica P, Brown LK. Communicating do-not-
resuscitate orders with a computer-based system. Arch Intern Med
1998;158:1090-1095.
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.
Dear Editor
Adding the element of safety to medical education can not be effected unless the institutions supplement their systems with program of outcomes assesment.
While all that Dr Stevens describes is of interest, only when it is established that the medical safety material that has been presented is absorbed and put into practice will the validity of the suggestions be established.
This req...
We thank Dr. Iedema for highlighting that a gap exists in providers having the skillset to 'work smarter.' We agree that novel approaches to healthcare improvement are required that move beyond gadget-based solutions and that require a new set of skills of providers and provider organizations. The suggestion of video taping one's performance to review how the system (and its participants) currently operates and reflect...
Dear Editor
I will call the work of giving Medicine to poor countries, a Great English men do this beautiful things. From a Professor of internal medicine - Jorge H Jimenez.
Thanks
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...
Dear Editor
As a member of the professional organisation for nurses in Ontario, I would like to direct nurses and other interested readers to the web page of the Registered Nurses Association of Ontario, www.rnao.org
This site has a wealth of position statements, policies, submissions to a variety of health stakeholders and other documents relating to providing...
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
I very much agree with the authors concerning the role of Risk Management in the Patient Safety arena. In fact, as a Director of Risk Managment in an integrated delivery system in Dayton, Ohio, I have been very involved in the patient safety efforts of our two acute care organizations, as well as the other entities within our system. My concern for the past few months has been how to best focus the ri...
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...
Dear Editor
I share much of Dr Morris' enthusiasm for decision support. While involved in an evaluation of a decision support targeting vancomycin ordering practice,[1] I had the opportunity to observe the potential impact of this approach. However, as a clinician using the same computerized order entry system in daily practice, I also recognized the major limitation of this approach: users will not tolerate many...
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...
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