Risk Watch (Sept '18)
Selected research, publications, and resources to promote evidence-informed risk management in Canadian healthcare organizations. Prepared by HIROC. Some titles are open access while others may require a subscription or library access; the librarian at your organization may be able to assist you. Please contact riskmanagement@hiroc.com for assistance if required.
Quality Improvement / Patient Engagement
Engaging patients to improve quality of care: a systematic review
Bombard Y, Baker GR, Orlando E, et al. Implement Sci. 2018 (July);13(1):1-22.
Study to identify the strategies and contextual factors that enable optimal patient engagement in the design, delivery, and evaluation of health services. Forty-eight studies were included in the review; strategies that contributed to optimal patient engagement were grouped into five themes: 1) design of engagement; 2) recruitment; 3) involvement; 4) creating a receptive context; 5) leadership actions. Studies using lower levels of patient engagement (i.e. patients in consultative role) derived discrete products (e.g. education materials, policies) while care process or structural outcomes resulted from higher levels of engagement (i.e. co-design). Authors noted mental health settings emerged as a frequent venue for patient engagement, and that senior leadership support is key to success as it increases the likelihood that findings are implemented. Facilitators and barriers in each of the themes are discussed.
Quality Improvement / Huddles
Gallant F, Budrevics G, D’Alimonte L. J Med Imaging Radiat Sci. 2018 (online May):1-5.
Quality improvement project at a Canadian teaching hospital to explore the value of huddles or quality conversations (QCs) to provide opportunities to integrate best practices, share staff concerns and solutions, and acknowledge success once solutions were implemented. A weekly 15-minute QC was conducted around a visual board with three guiding questions and sections for data, change ideas, future topics, and celebrations. Plan-do-study-act cycles were used to guide change ideas from inception to completion. Post-evaluation after the three-month pilot period showed decreases in staff awareness of the six elements of quality (20%) and of best practices (32%), suggesting more time should be focused on these subjects. However, staff reported regular QCs will improve quality and safety on the unit. Authors noted QCs are designed to help minimize delays in implementing best practices. A sample of the QC board is included.
Patient Safety
Transforming concepts in patient safety: a progress report
Gandhi T, Kaplan G, Leape L, et al. BMJ Qual Saf. 2018 (online July):1-8.
Article assessing progress made in advancing patient safety in the US since 2009 and the remaining challenges around five system-level action areas: 1) medical education redesign, 2) care integration, 3) joy and meaning in work and workforce safety, 4) patient and family engagement, 5) transparency as a practiced value. Authors noted common themes included the need for leadership commitment to build operational safety cultures to advance the five concepts, for meaningful measurement, and for research to advance understanding and improvement capability of safety concepts. Key recommendations in each of the areas are highlighted.
Quality Improvement / Patient Safety
Vaughn V, Saint S, Krein S, et al. BMJ Qual Saf. 2018 (online first, July):1-11.
Systematic review of qualitative studies to explore factors associated with struggling healthcare organisations with below-average patient outcomes or quality of care metrics and to summarize these factors into actionable domains. Thirty studies from multiple countries and healthcare sectors such as; acute care, nursing homes, paediatric, and outpatient care was included in the analysis. Results showed five domains characterized struggling healthcare organizations including: poor organisational culture, inadequate infrastructure, lack of cohesive mission, system shocks and dysfunctional external relations with other hospitals, stakeholders or governing bodies. Associated themes with each domain are included in the article. Authors concluded struggling organisations share characteristics that may affect their ability to provide optimal care and identifying these may provide a first step to addressing challenges to improvement.
Patient Safety / Clinical Documentation
Zhou L, Blackley S, Kowalski L, et al. JAMA Network Open. 2018 (online, July):1-13.
Study to explore and analyze errors at each stage of speech recognition assisted dictation process used by clinicians. Authors noted that documentation errors can put patients at significant risk of harm. Reviewed was a random sample for error rate of 217 notes including 83 office notes, 75 discharge summaries and 59 operative notes from hospitals at two United States health care organizations. An error was considered clinically significant if it could plausibly change a note’s interpretation, thereby potentially affecting a patient’s future care directly (e.g. by influencing clinical decisions) or indirectly (e.g. by affecting litigation proceedings). Results showed seven in 100 words (7.4%) in unedited clinical documents created with speech recognition software involved errors and one in 250 words contained clinically significant errors. The error rate decreased to 0.4% after transcriptionist review and 0.3% in physicians signed notes which authors highlighted the crucial role of manual editing.
Care / Suicide
Stanley B, Brown G, Brenner, et al. JAMA Psychiatry. 2018 (online first, July):E1-E7.
Study to understand whether a safety planning intervention (SPI) administered in the emergency department (ED) combined with two follow-up telephone contacts for suicidal patients was associated with reduced suicidal behaviour and improved outpatient treatment engagement post discharge. The cohort comparison design study occurred in nine US Veterans Health Administration hospital emergency departments. Of the 1640 total patients, 1186 were in the intervention group and 454 were in the comparison group. Results showed patients who visited the ED for suicide related concerns and received the SPI and structured follow up calls to assess risk, review and revise the safety plan and support treatment engagement had 45% fewer suicidal behaviours over six months following a suicidal crisis. Patients in the intervention group were more than twice as likely to attend mental health treatment during the six month follow-up period compared with their counterparts who received the usual care following their ED visit.
Furqan Z, Sinyor M, Schaffer A, et al. Can J Psychiatry. 2018 (online July):1-9.
Study to explore the subjectivity of mental illness and treatment experiences through the study sample of 36 suicide notes from individuals who lived in Toronto prior to their death. Twenty of the individuals wrote about their experiences with mental health treatment. Results showed three themes which are depicted in a model indicating the pathways to suicide: negotiating personal agency in the context of mental illness; conflict between self and illness; and experiences of mental health treatment leading to feelings of hopelessness and self-blame. Authors identified three implications for clinicians: eliciting and addressing beliefs about mental illness and treatment; addressing exhaustion; and enhancing self-efficacy without suicidal behaviour. Composite quotes addressing each theme are included.
Care / Senior's Strategy
Sinha S, Bennett J, Ramsden R, et al. Healthc Manag Forum. 2018 (June);31(4):126-132.
Article describing the effectiveness of a Canadian intervention (Acute Elder Care for Elders [ACE] Strategy) to improve the care of hospitalized older adults across the continuum over a six-year period. Results showed a decrease in total lengths of stay and readmissions and a reduction in the direct costs of care per patient despite a 53% increase in annual admissions of older patients. This led to a net savings of $4.2M in 2014/15 at a Canadian teaching hospital. Article includes four ACE guiding principles, portfolio components, and conceptual diagram depicting models of care and care practices across the continuum.
“Overall, the three greatest challenges observed in implementing this level of inter- and intra-organizational change included changing deeply engrained ways of traditional thinking…; ensuring that the hospital’s frontline providers had the necessary knowledge, skills, attitudes, and tools needed to care effectively for an older population; and making certain that the right home, community, and primary care partnerships were developed and supported to ensure that a true continuum of care could be established that could enable patients to avoid hospitalization, return home and remain well-supported in the community as soon as and whenever possible” (p.131).
Care / Transitions
Decreasing preventable emergency department transfers for long-term care residents using PREVIEW-ED©
ElBestawi M, Kohm C. Healthc Manag Forum. 2018 (June);31(4):137-141.
Article describing a method (Practical Routine Elder Variants Indicate Early Warning for Emergency Department - PREVIEW-ED) utilized in two Canadian pilot studies. The goal of the tool is to assist in the identification of preventable conditions and early health decline in Long Term Care (LTC) residents, reduce ED transfers from LTC, and leverage the personal support worker workforce. Four preventable conditions were selected as the focus of the studies: pneumonia, urinary tract infection, congestive heart failure, and dehydration. Results showed the target of 25% reduction in preventable ED transfers was surpassed in both pilots. Authors identified health leaders can benefit in several way such as: improved ED utilization, fewer transfers to the ED, and reduced costs.
Other Resources of Interest
Environmental scan 2018 (August 2018). Association of General Hospital Psychiatric Services (CDN) summary report for leaders and stakeholders on current practices related to high priority issues of psychiatric facilities.
Frameworks for self-management support for chronic disease: a cross-country comparative document analysis (July 2018). BMC Health Services Research (UK) journal article on review of eight frameworks in Organisation for Economic Cooperation and Development countries.
Health IT safe practices for closing the loop (July 2018). Partnership for Health IT Patient Safety (US) toolkit on safe practice recommendations using Health IT to assist in mitigating delayed, missed or incorrect diagnoses.
No place like home: advancing the safety of care in the home (July 2018). Institute for Healthcare Improvement (US) report highlighting the challenges to safety in the home setting; includes five guiding principles for advancing home care safety, and strategies and tools to put these strategies into action.
Nurses as substitutes for doctors in primary care (July 2018). Cochrane (US) review on how primary healthcare services delivered by nurses instead of doctors can lead to similar or better patient health outcomes and higher patient satisfaction.
Palliative care: care for adults with a progressive, life-limiting illness (June 2018). Health Quality Ontario quality standard focusing on care for people living with serious, life-limiting illness in all care settings.
Patients’ roles and rights in research (July 2018). BMJ (UK) editorial compelling researchers to collaborate with patients and the public in their clinical work.
Taking a holistic view of safety: the framework for measuring and monitoring safety (June 2018). Canadian Patient Safety Institute article highlighting improvement in safety culture using the measuring framework.
Ten things to know now that recreational cannabis will be legal in Canada (July 2018). Borden Ladner Gervais LLP (CDN) article highlighting recent developments around cannabis legalization.
Three essential resources to help you work collaboratively (July 2018). The Health Foundation (UK) article on three separate resources for collaboration of; problem solving, liberating structures, and special interest groups
Watch your step! Falls are sending more Canadians to the hospital than ever before (July 2018). Canadian Institute for Health Information article summarizing 2016-2017 data on unintentional falls.