Quality and safety in intensive care-A means to an end is critical

Our study has commenced the development of an international taxonomy of errors in primary care which can be used to plan future studies examining the prevalence of mistakes in general practice. The strength of an international collaboration will become apparent when meaningful differences between countries are defined in the prevalence of different error types. This information can then be used to design interventions or alter existing systems to reduce errors in primary care.

General Practice Research

‘Facts’ and ‘myths’ about clinical research

Optimising the quality of care is an imperative for health services worldwide, including in Australia. Recognition that poor quality often has its roots in system failures is beginning to shift strategies for improvement to the systems of care, although the tendency remains to focus on eliminating the practice variations of individual clinicians. In those instances where systems improvement is addressed, strategies tend to be generic and technical, and often unrelated to the context in which they are applied. This paper reports an interim evaluation of a quality management program in cancer services implemented in a Sydney metropolitan teaching hospital dispersed across multiple campuses. The paper aims to inform the debate on quality improvement by reporting not only on what was achieved, but why change seems to be so hard. We found that organisational and social factors that influence the quality of health services were not sufficiently addressed, compared with technical factors. We conclude that service quality needs to be repositioned as an organisational goal, and implemented via a structured process that addresses organisational and social factors, as well as technical factors.

/pdf/managing-quality-in-cancer-services-why-improvement-isn-t-4nwzv8k97v.pdf

Managing quality in cancer services: why improvement isn't easy.

The need for comprehensive and effective methods to ensure the delivery of required processes of care to intensive care unit (ICU) patients is acknowledged globally. In response various tools have been implemented, although many have not yet been empirically tested or rigourously evaluated in ICUs. Early evidence suggests that using a checklist is one way of ensuring evidence-based or accepted processes of care are performed routinely and systematically.
The aim of this program of study was to identify areas of need, then develop, validate, test and evaluate an electronic process-of-care checklist (e-checklist) for use by intensive care physicians during morning ward rounds in a tertiary-level adult ICU. Need for improvements in the delivery of ICU processes of care were identified via a comprehensive literature search, a point prevalence study of 50 Australian and New Zealand ICUs, and baseline data collected at the local ICU level.
Evidence on checklist validity was obtained via multiple methods at different research stages: comparison of checklist responses and documentation of care recorded in patients’ medical records demonstrated high correlations for each care component, providing support for its concurrent validity; local clinician interviews and a modified-Delphi technique using an expert clinician panel confirmed the relevance and adequacy of content and produced a list of clear, concise and descriptive checklist statements; high levels of concordance between clinician and auditor responses during the intervention phase contributed evidence to the e- checklist’s construct validity based on response processes; and user feedback obtained before and after the intervention demonstrated the e-checklist had face validity with ICU physicians. Importantly, the prospective before-after intervention study demonstrated improved compliance with processes of care over time (odds ratios ranged from 1.9 for mechanical ventilation weaning to 22.9 for pain management) and user-satisfaction was achieved.
Implications for practice include implementing this versatile tool at the point-of-care to collect real-time, process-of-care data that can be completed by clinicians delivering and auditing care. Recommendations for further research include: testing for reliability; investigating the reasons for practice variability and impact on outcomes; conducting observations of e-checklist utility in clinical practice and in larger multi-centre studies adequately powered to detect significant differences in patient outcomes over time; and comparing the e-checklist with other clinical support tools or across different delivery platforms such as tablet PCs.
Overall, this research demonstrated the utility of an e-checklist in measuring and improving the delivery of ICU processes of care and provided a substantial amount of evidence in support of its’ construct validity.

/pdf/process-of-care-in-the-icu-a-multi-method-exploration-of-an-3k6vb1wmdb.pdf

Process-of-care in the ICU : a multi-method exploration of an electronic checklist to support medical morning rounds

TO THE EDITOR: The recent creation of the National Institute for Clinical Studies (NICS) is an exciting new opportunity for bridging the gap between evidence and practice.1 In carrying out this task, NICS will be directed by the members of its Board. Balanced stakeholder representation on the Board is required for NICS to produce optimal results. At present the Board consists of nine members, of whom eight are medical practitioners. The importance of doctors in the process and implementation of quality improvement initiatives is indisputable. However, other healthcare professionals also play a central role in achieving quality health outcomes for patients.2 Board membership more representative of its stakeholders would provide NICS with a broader range of perspectives, which could only be seen as beneficial. Given the current debate surrounding ethics and evidence-based healthcare, the values and expectations of healthcare consumers also need to be taken into account.3 One of the definitions of quality in healthcare is “consistently meeting or exceeding informed customers’ opinion”.4 It is crucial that the consumer’s voice be heard in matters relating to healthcare research and in the implementation of quality initiatives. As the relevance and acceptability of quality initiatives undertaken by NICS will have an impact on health outcomes for consumers, it is important that such initiatives take into account the preferences of consumers. For this reason, we believe it is imperative that NICS include a consumer on its Board. An example of successful integration of a wide range of stakeholders onto a board is the Federal Government-funded National Health Priority Action Council, with representation from State/Territory, Indigenous and consumer groups and a balanced gender mix. We hope that NICS has strategies in place to enhance stakeholder representation on its Board, as this may be a factor in determining whether or not NICS becomes another forgettable acronym.

Evidence-based healthcare 10 years on: is the National Institute of Clinical Studies the answer?

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Evidence-based healthcare 10 years on: is the National Institute of Clinical Studies the answer?