Safer clinical systems : interim report, August 2010

Safer Clinical Systems is the Health Foundation’s new five year programme of work to test and demonstrate ways to improve healthcare systems and processes, to develop safer systems that improve patient safety. It builds on learning from the Safer Patients Initiative (SPI) and models of system improvement from both healthcare and other industries. Learning from the SPI highlighted the need to take a clinical systems approach to improving safety. SPI highlighted that many hospitals struggle to implement improvement in clinical areas due to inherent problems with support mechanisms. Clinical processes and systems, rather than individuals, are often the contributors to breakdown in patient safety. The Safer Clinical Systems programme aimed to measure the reliability of clinical processes, identify defects within those processes, and identify the systems that result in those defects. Methods to improve system reliability were then to be tested and re-developed in order to reduce the risk of harm being caused to patients. Such system-level awareness should lead to improvements in other patient care pathways. The relationship between system reliability and actual harm is challenging to identify and measure. Specific, well-defined, small-scale processes have been used in other programmes, and system reliability has been shown to have a direct causal relationship with harm (e.g. care bundle compliance in an intensive care unit can reduce the incidence of ventilator-associated pneumonia). However, it has become evident that harm can be caused by a variety of factors over time; when working in broader, more complex and dynamic systems, change in outcome can be difficult to attribute to specific improvements and difficulties are also associated with relating evidence to resulting harm. The overall aim of Phase 1 of the Safer Clinical Systems programme was to demonstrate proof-of-concept that using a systems-based approach could contribute to improved patient safety. In Phase 1, experienced NHS teams from four locations worked together with expert advisers to co-design the Safer Clinical Systems programme

Evaluating candidate reactions to selection practices using organisational justice theory

Objectives: This study aimed to examine candidate reactions to selection practices in postgraduate medical training using organisational justice theory. Methods: We carried out three independent cross-sectional studies using samples from three consecutive annual recruitment rounds. Data were gathered from candidates applying for entry into UK general practice (GP) training during 2007, 2008 and 2009. Participants completed an evaluation questionnaire immediately after the short-listing stage and after the selection centre (interview) stage. Participants were doctors applying for GP training in the UK. Main outcome measures were participants’ evaluations of the selection methods and perceptions of the overall fairness of each selection stage (short-listing and selection centre). Results: A total of 23 855 evaluation questionnaires were completed (6893 in 2007, 10 497 in 2008 and 6465 in 2009). Absolute levels of perceptions of fairness of all the selection methods at both the short-listing and selection centre stages were consistently high over the 3 years. Similarly, all selection methods were considered to be job-related by candidates. However, in general, candidates considered the selection centre stage to be significantly fairer than the short-listing stage. Of all the selection methods, the simulated patient consultation completed at the selection centre stage was rated as the most job-relevant. Conclusions: This is the first study to use a model of organisational justice theory to evaluate candidate reactions during selection into postgraduate specialty training. The high-fidelity selection methods are consistently viewed as more job-relevant and fairer by candidates. This has important implications for the design of recruitment systems for all specialties and, potentially, for medical school admissions. Using this approach, recruiters can systematically compare perceptions of the fairness and job relevance of various selection methods

From theory to 'measurement' in complex interventions: methodological lessons from the development of an e-health normalisation instrument

<b>Background</b> Although empirical and theoretical understanding of processes of implementation in health care is advancing, translation of theory into structured measures that capture the complex interplay between interventions, individuals and context remain limited. This paper aimed to (1) describe the process and outcome of a project to develop a theory-based instrument for measuring implementation processes relating to e-health interventions; and (2) identify key issues and methodological challenges for advancing work in this field.<p></p> <b>Methods</b> A 30-item instrument (Technology Adoption Readiness Scale (TARS)) for measuring normalisation processes in the context of e-health service interventions was developed on the basis on Normalization Process Theory (NPT). NPT focuses on how new practices become routinely embedded within social contexts. The instrument was pre-tested in two health care settings in which e-health (electronic facilitation of healthcare decision-making and practice) was used by health care professionals.<p></p> <b>Results</b> The developed instrument was pre-tested in two professional samples (N = 46; N = 231). Ratings of items representing normalisation 'processes' were significantly related to staff members' perceptions of whether or not e-health had become 'routine'. Key methodological challenges are discussed in relation to: translating multi-component theoretical constructs into simple questions; developing and choosing appropriate outcome measures; conducting multiple-stakeholder assessments; instrument and question framing; and more general issues for instrument development in practice contexts.<p></p> <b>Conclusions</b> To develop theory-derived measures of implementation process for progressing research in this field, four key recommendations are made relating to (1) greater attention to underlying theoretical assumptions and extent of translation work required; (2) the need for appropriate but flexible approaches to outcomes measurement; (3) representation of multiple perspectives and collaborative nature of work; and (4) emphasis on generic measurement approaches that can be flexibly tailored to particular contexts of study

Softer perspectives on enhancing the patient experience using IS/IT

Purpose – This paper aims to argue that the implementation of the Choose and Book system has failed due to the inability of project sponsors to appreciate the complex and far-reaching softer implications of the implementation, especially in a complex organisation such as the NHS, which has multifarious stakeholders. Design/methodology/approach – The authors use practice-oriented research to try and isolate key parameters. These parameters are compared with existing conventional thinking in a number of focused areas. Findings – Like many previous NHS initiatives, the focus of this system is in its obvious link to patients. However we find that although this project has cultural, social and organisational implications, programme managers and champions of the Connecting for Health programme emphasised the technical domains to IS/IT adoption. Research limitations/implications – This paper has been written in advance of a fully implemented Choose and Book system. Practical implications – The paper requests that more attention be paid to the softer side of IS/IT delivery, implementation, introduction and adoption. Originality/value – The paper shows that patient experience within the UK healthcare sector is still well below what is desired

Clinical quality improvement and medicine

Medical practice is facing many pressures, all requiring ever-higher standards and better 'quality' in the provision of clinical care. Medicine is not alone in facing such forces, and it may be appropriate to apply the methodology used in other disciplines to address this issue; common problems are generally amenable to common solutions. The 'quality' approach was initially applied to health care in the USA, presumably because of the accent on market forces and the relationship with market share. In recent years, other health care systems have invested in this approach, applying lessons learned from management disciplines and the aviation industly. The Institute of Medicine's report on health care quality noted that 'every system is perfectly designed to obtain the results it gets' fll The European Union has thus far not included quality as a formal item on its agenda; however, with increasing mobility of patients and health professionals, there is pressure for legislative action addressing risk management and quality improvement. The development of a European approach to ensure the highest quality standards, free movement in the European Union, as well as the medical devices industry, are all areas that are raising interest. Overall, it behooves the individual clinician to be aware of developments in the area.peer-reviewe

Models for schools of public health: A scoping review and synthesis of existing evidence

The final report on 'Models for schools of public health: A scoping review and synthesis of existing evidence' produced by Steven, Lombardo and Goodall and commissioned by Public Health Gateshead is now available. To date, existing evidence regarding models (organisational, structural, managerial, administrational) for Schools of Public Health (SsPH) has not been systematically collected or synthesised. This study aims to begin to fill that gap by using a combination of rapid review and scoping review techniques to retrieve and assess existing literature to identify potential and existing models, themes and issues and where possible highlight strengths and weaknesses