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What matters to medical ward patients, and do we measure it? A qualitative comparison of patient priorities and current practice in quality measurement, on UK NHS medical wards.

ABSTRACT: OBJECTIVES:To compare the quality metrics selected for public display on medical wards to patients' and carers' expressed quality priorities. METHODS:Multimodal qualitative evaluation of general medical wards and semi-structured interviews. SETTING:UK tertiary National Health Service (public) hospital. PARTICIPANTS:Fourteen patients and carers on acute medical wards and geriatric wards. RESULTS:Quality metrics on public display evaluated hand hygiene, hospital-acquired infections, nurse staffing, pressure ulcers, falls and patient feedback. The intended audience for these metrics was unclear, and the displays gave no indication as to whether performance was improving or worsening. Interviews identified three perceived key components of high-quality ward care: communication, staff attitudes and hygiene. These aligned poorly with the priorities on display. Suboptimal performance reporting had the potential to reduce patients' trust in their medical teams. More philosophically, patients' and carers' ongoing experiences of care would override any other evaluation, and they felt little need for measures relating to previous performance. The display of performance reports only served to emphasise patients' and carers' lack of control in this inpatient setting. CONCLUSIONS:There is a gap between general medical inpatients' care priorities and the aspects of care that are publicly reported. Patients and carers do not act as 'informed choosers' of healthcare in the inpatient setting, and tokenistic quality measurement may have unintended consequences.

SUBMITTER: Pannick S

PROVIDER: S-EPMC6475203 | biostudies-literature | 2019 Mar

REPOSITORIES: biostudies-literature

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What matters to medical ward patients, and do we measure it? A qualitative comparison of patient priorities and current practice in quality measurement, on UK NHS medical wards.

Pannick Samuel S Archer Stephanie S Long Susannah Jane SJ Husson Fran F Athanasiou Thanos T Sevdalis Nick N

BMJ open 20190330 3

<h4>Objectives</h4>To compare the quality metrics selected for public display on medical wards to patients' and carers' expressed quality priorities.<h4>Methods</h4>Multimodal qualitative evaluation of general medical wards and semi-structured interviews.<h4>Setting</h4>UK tertiary National Health Service (public) hospital.<h4>Participants</h4>Fourteen patients and carers on acute medical wards and geriatric wards.<h4>Results</h4>Quality metrics on public display evaluated hand hygiene, hospital ...[more]

PMID: 30928929

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Project description:OBJECTIVE:The positive deviance approach seeks to identify and learn from exceptional performers. Although a framework exists to apply positive deviance within healthcare organisations, there is limited guidance to support its implementation. The approach has also rarely explored exceptional performance on broad outcomes, been implemented at ward level, or applied within the UK. This study develops and critically appraises a pragmatic method for identifying positively deviant wards using a routinely collected, broad measure of patient safety. DESIGN:A two-phased observational study was conducted. During phase 1, cross-sectional and temporal analyses of Safety Thermometer data were conducted to identify a discrete group of positively deviant wards that consistently demonstrated exceptional levels of safety. A group of matched comparison wards with above average performances were also identified. During phase 2, multidisciplinary staff and patients on the positively deviant and comparison wards completed surveys to explore whether their perceptions of safety supported the identification of positively deviant wards. SETTING:34 elderly medical wards within a northern region of England, UK. PARTICIPANTS:Multidisciplinary staff (n=161) and patients (n=188) clustered within nine positively deviant and comparison wards. RESULTS:Phase 1: A combination of analyses identified five positively deviant wards that performed best in the region, outperformed their organisation and performed consistently well over 12 months. Five above average matched comparator wards were also identified. Phase 2: Staff and patient perceptions of safety generally supported the identification of positively deviant wards using Safety Thermometer data, although patient perceptions of safety were less concordant with the routinely collected data. CONCLUSIONS:This study tentatively supports a pragmatic method of using routinely collected data to identify positively deviant elderly medical wards; however, it also highlights the various challenges that are faced when conducting the first stage of the positive deviance approach. TRIAL REGISTRATION NUMBER:UK Clinical Research Network Portfolio (reference-18050).

Project description:BackgroundExtravasation injuries are caused by unintended leakages of fluids or medicines from intravenous lines but there is no consensus on the best treatment approaches, particularly in infants and young children.MethodsThis paper presents a more succinct account of a study of treatments for extravasation injuries in infants and children which has also been reported in full as an NIHR HTA report. A systematic scoping review and survey of UK NHS practice were undertaken. Twelve databases - including MEDLINE and EMBASE - were searched for relevant studies in February 2017. Studies of children with extravasation injuries receiving any treatment for extravasation injury were eligible, providing they reported one of the following outcomes: wound healing time, infection, pain, scarring, functional impairment, and requirement for surgery. Studies were screened in duplicate. Data were extracted by one researcher and checked by another. Studies were summarised narratively. An online questionnaire was distributed to NHS staff at neonatal units, paediatric intensive care units and principal oncology/haematology units.ResultsThe evidence identified in the scoping review was mostly comprised of small, retrospective, uncontrolled group studies or case reports. The studies covered a wide range of interventions including conservative management approaches, saline flush-out techniques (with or without prior hyaluronidase), hyaluronidase without flush-out, artificial skin treatments, debridement and plastic surgery. Few studies graded injury severity and the results sections and outcomes reported in most studies were limited. There was heterogeneity across study populations in many factors. The survey yielded 63 responses from hospital units across the UK. Results indicated that although most units had written documentation for treating extravasation injuries, only one-third of documents included a system for grading injury severity. The most frequently used interventions were elevation of the affected area and analgesics. Saline wash-out treatments, either with or without hyaluronidase, were regularly used in about half of all neonatal units. Most responders thought a randomised controlled trial might be a viable future research design.ConclusionsThere is some uncertainty about which are most the promising treatments for extravasation injuries in infants and young children. Saline flush-out techniques and conservative management approaches are commonly used and may be suitable for evaluation in trials. Although conventional randomised trials may be difficult to perform a randomised registry trial may be an appropriate alternative design.

Project description:BackgroundCronbach's alpha is widely used as the preferred index of reliability for medical postgraduate examinations. A value of 0.8-0.9 is seen by providers and regulators alike as an adequate demonstration of acceptable reliability for any assessment. Of the other statistical parameters, Standard Error of Measurement (SEM) is mainly seen as useful only in determining the accuracy of a pass mark. However the alpha coefficient depends both on SEM and on the ability range (standard deviation, SD) of candidates taking an exam. This study investigated the extent to which the necessarily narrower ability range in candidates taking the second of the three part MRCP(UK) diploma examinations, biases assessment of reliability and SEM.Methodsa) The interrelationships of standard deviation (SD), SEM and reliability were investigated in a Monte Carlo simulation of 10,000 candidates taking a postgraduate examination. b) Reliability and SEM were studied in the MRCP(UK) Part 1 and Part 2 Written Examinations from 2002 to 2008. c) Reliability and SEM were studied in eight Specialty Certificate Examinations introduced in 2008-9.ResultsThe Monte Carlo simulation showed, as expected, that restricting the range of an assessment only to those who had already passed it, dramatically reduced the reliability but did not affect the SEM of a simulated assessment. The analysis of the MRCP(UK) Part 1 and Part 2 written examinations showed that the MRCP(UK) Part 2 written examination had a lower reliability than the Part 1 examination, but, despite that lower reliability, the Part 2 examination also had a smaller SEM (indicating a more accurate assessment). The Specialty Certificate Examinations had small Ns, and as a result, wide variability in their reliabilities, but SEMs were comparable with MRCP(UK) Part 2.ConclusionsAn emphasis upon assessing the quality of assessments primarily in terms of reliability alone can produce a paradoxical and distorted picture, particularly in the situation where a narrower range of candidate ability is an inevitable consequence of being able to take a second part examination only after passing the first part examination. Reliability also shows problems when numbers of candidates in examinations are low and sampling error affects the range of candidate ability. SEM is not subject to such problems; it is therefore a better measure of the quality of an assessment and is recommended for routine use.

Project description:BackgroundIt is well known that many healthcare systems have poor reliability; however, the size and pervasiveness of this problem and its impact has not been systematically established in the UK. The authors studied four clinical systems: clinical information in surgical outpatient clinics, prescribing for hospital inpatients, equipment in theatres, and insertion of peripheral intravenous lines. The aim was to describe the nature, extent and variation in reliability of these four systems in a sample of UK hospitals, and to explore the reasons for poor reliability.MethodsSeven UK hospital organisations were involved; each system was studied in three of these. The authors took delivery of the systems' intended outputs to be a proxy for the reliability of the system as a whole. For example, for clinical information, 100% reliability was defined as all patients having an agreed list of clinical information available when needed during their appointment. Systems factors were explored using semi-structured interviews with key informants. Common themes across the systems were identified.ResultsOverall reliability was found to be between 81% and 87% for the systems studied, with significant variation between organisations for some systems: clinical information in outpatient clinics ranged from 73% to 96%; prescribing for hospital inpatients 82-88%; equipment availability in theatres 63-88%; and availability of equipment for insertion of peripheral intravenous lines 80-88%. One in five reliability failures were associated with perceived threats to patient safety. Common factors causing poor reliability included lack of feedback, lack of standardisation, and issues such as access to information out of working hours.ConclusionsReported reliability was low for the four systems studied, with some common factors behind each. However, this hides significant variation between organisations for some processes, suggesting that some organisations have managed to create more reliable systems. Standardisation of processes would be expected to have significant benefit.

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What matters to medical ward patients, and do we measure it? A qualitative comparison of patient priorities and current practice in quality measurement, on UK NHS medical wards.

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What matters to medical ward patients, and do we measure it? A qualitative comparison of patient priorities and current practice in quality measurement, on UK NHS medical wards.

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