Analysing 'big picture' policy reform mechanisms: The Australian health service safety and quality accreditation scheme

© 2015 John Wiley & Sons Ltd. Background: Agencies promoting national health-care accreditation reform to improve the quality of care and safety of patients are largely working without specific blueprints that can increase the likelihood of success. Objective: This study investigated the development and implementation of the Australian Health Service Safety and Quality Accreditation Scheme and National Safety and Quality Health Service Standards (the Scheme), their expected benefits, and challenges and facilitators to implementation. Methods: A multimethod study was conducted using document analysis, observation and interviews. Data sources were eight government reports, 25 h of observation and 34 interviews with 197 diverse stakeholders. Results: Development of the Scheme was achieved through extensive consultation conducted over a prolonged period, that is, from 2000 onwards. Participants, prior to implementation, believed the Scheme would produce benefits at multiple levels of the health system. The Scheme offered a national framework to promote patient-centred care, allowing organizations to engage and coordinate professionals' quality improvement activities. Significant challenges are apparent, including developing and maintaining stakeholder understanding of the Scheme's requirements. Risks must also be addressed. The standardized application of, and reliable assessment against, the standards must be achieved to maintain credibility with the Scheme. Government employment of effective stakeholder engagement strategies, such as structured consultation processes, was viewed as necessary for successful, sustainable implementation. Conclusion: The Australian experience demonstrates that national accreditation reform can engender widespread stakeholder support, but implementation challenges must be overcome. In particular, the fundamental role of continued stakeholder engagement increases the likelihood that such reforms are taken up and spread across health systems

Patient and nurse preferences for implementation of bedside handover: Do they agree? Findings from a discrete choice experiment

Objective: To describe and compare patients' and nurses' preferences for the implementation of bedside handover. Design: Discrete choice experiment describing handover choices using six characteristics: whether the patient is invited to participate; whether a family member/carer/friend is invited; the number of nurses present; the level of patient involvement; the information content; and privacy. Setting: Two Australian hospitals. Participants: Adult patients (n=401) and nurses (n=200) recruited from medical wards. Main outcome measures: Mean importance scores for handover characteristics estimated using mixed multinomial logit regression of the choice data. Results: Both patient and nurse participants preferred handover at the bedside rather than elsewhere (P<.05). Being invited to participate, supporting strong two-way communication, having a family member/carer/friend present and having two nurses rather than the nursing team present were most important for patients. Patients being invited to participate and supporting strong two-way communication were most important for nurses. However, contrary to patient preferences, having a family member/carer/friend present was not considered important by nurses. Further, while patients expressed a weak preference to have sensitive information handed over quietly at the bedside, nurses expressed a relatively strong preference for handover of sensitive information verbally away from the bedside. Conclusions: All participants strongly support handover at the bedside and want patients to participate although patient and nurse preferences for various aspects of bedside handover differ. An understanding of these preferences is expected to support recommendations for improving the patient hospital experience and the consistent implementation of bedside handover as a safety initiative

Challenges and Opportunities for Disinvestment in Australia: A need to evaluate the implementation and impact of Choosing Wisely in Australia

Purpose – Worldwide, there is significant growth in the cost of (and demand for) healthcare, which often clashes with a requirement to contain expenditure. This duality leads to an increasing need for a systematic approach to disinvestment in health technologies. The purpose of this paper is to consider the challenges and opportunities for disinvestment policy decisions in Australia. It discusses the implementation of the Choosing Wisely campaign and the need for rigorous evaluation of such campaigns in the Australian healthcare system. Design/methodology/approach – The authors highlight characteristics of disinvestment: what it is and what it is not and discuss international examples of identifying low value care, including the recent Choosing Wisely initiative. The authors discuss the barriers to implementing initiatives such as Choosing Wisely and the complexities in evaluating their effectiveness. Findings – While the primary purpose of the Choosing Wisely campaign is improved decision making through clinical engagement, it is expected that implementation could lead to resource savings alongside improvements in patient safety and service quality. While there is research looking to understand the barriers and facilitators to the implementation of initiatives such as Choosing Wisely, little is known about broader patient impacts, and more attention on the quantification of their effect on both patient outcomes and resource use is needed. Originality/value – This work highlights the limited knowledge around implementation of disinvestment strategies and the paucity of research around the impact of strategies such as Choosing Wisely in the Australian public hospital system. This is important as future research in this area will give greater certainty about the benefits and consequences of Choosing Wisely leading to improved opportunities for resource savings and patient safety and quality

Increasing the options for reducing adverse events: Results from a modified Delphi technique

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background: The aim of this paper is to illustrate a simple method for increasing the range of possible options for reducing adverse events in Australian hospitals, which could have been, but was not, adopted in the wake of the landmark 1995 &apos;Quality in Australian Health Care &apos; study, and to report the suggestions and the estimated lapse time before they would impact upon mortality and morbidity. Method: The study used a modified Delphi technique that first elicited options for reducing adverse events from an invited panel selected on the basis of their knowledge of the area of adverse events and quality assurance. Initial suggestions were collated and returned to them for reconsideration and comment. Results: Completed responses from both stages were obtained from 20 of those initially approached. Forty-one options for reducing AEs were identified with an average lapse time of 3.5 years. Hospital regulation had the least delay (2.4 years) and out of hospital information the greatest (6.4 years). Conclusion: Following identification of the magnitude of the problem of adverse events in the &apos;Quality in Australian Health Care &apos; study a more rapid and broad ranging response was possible than occurred. Apparently viable options for reducing adverse events and associated mortality and morbidity remain unexploited

Activity-based funding for safety and quality: a policy discussion of issues and directions for nursing-focused health services outcomes research

AIMS: A discussion of the implications and opportunities arising from the Commonwealth of Australia health care reform agenda; linking pricing with quality, with particular reference to directions for nursing‐focused health services outcomes research directed to improve the safety and quality of health care practices. BACKGROUND: National activity‐based funding in Australia is a policy‐focused development. As the relationship between cost and quality becomes apparent, the role of clinicians and their contribution to high quality care has become a pressing issue for leadership, teaching, and research. DESIGN: Discussion paper DATA SOURCES: This paper is based on seven years' experience as a member of a Commonwealth of Australia statutory committee—the Clinical Advisory Committee of the Independent Hospital Pricing Authority—and is supported by relevant literature and theory. IMPLICATIONS FOR NURSING: To date, unravelling the linkage, especially causal relationships, between direct care nursing and patient safety outcomes has not been well established. New activity‐based funding data elements developed for national implementation in Australia provide accessible and meaningful standardised data for measurement of never events, hospital‐acquired complications, and preventable readmissions

Development and content validation of the Burden of Documentation for Nurses and Midwives (BurDoNsaM) survey

Aim: To develop a validated tool to measure nursing and midwifery documentation burden. Background: While an important record of care, documentation can be burdensome for nurses and midwives and may remove them from direct patient care, resulting in decreased job satisfaction, associated with decreased patient satisfaction. The amount of documentation is increasing at a time where staff rationalisation results in decreasing numbers of clinicians at the bedside. No instrument is available to measure staff perceptions of the burden of clinical documentation. Design: Survey development, followed by rwo rounds of content validation (April and May 2019). Methods: Based on the literature a 28 item survey, with items in 6 subscales, representing key areas of documentation burden was developed. Item (I-CVI), subscale (S-CVI/Ave by subscale) and overall content validity indexes (S-CVI/Ave) were calculated following two review rounds by an expert panel of clinical and academic nurses and midwives. Results: Level of agreement for the first iteration of the survey was low, with many items failing to reach the critical I-CVI threshold of 0.78. No subscale reached a S-CVI/Ave above 0.8 and the overall scale only achieved a S-CVI/Ave score of 0.67. Thirteen items were removed, seven were edited and five new items added, based on the expert panel feedback, substantially improving the content validity. All individual items achieved an I-CVI ≥0.78, the S-CVI/Ave was above 0.85 for all subscales and the total S-CVI/Ave was 0.94. Conclusion: The Burden of Documentation for Nurses and Midwives (BurDoNsaM) survey can be considered as content valid, according to the content validity analysis by an expert panel. Impact: The BurDoNsaM survey may be used by nurse leaders and researchers to measure the burden of documentation, providing the opportunity to review practice and implement strategies to decrease documentation burden, potentially improving patient satisfaction with the care received

The influence of adaptive challenge on engagement of multidisciplinary staff in standardising aseptic technique in an emergency department: A qualitative study

Aims and objectives: To explore the challenge of engaging multidisciplinary staff in standardising aseptic technique (AT) in an emergency department (ED) in an Australian tertiary hospital, and to better understand the enablers and barriers to implementing practice change within this setting. Background: Healthcare‐associated infections are the most common complication for patients in acute care. A clinical practice framework developed in the United Kingdom (UK) standardised AT practice to reduce potential infection risk. One Australian tertiary hospital drew upon this framework to similarly improve clinical practice. It was understood that standardising practice would require some practitioners only to revisit and demonstrate AT principles already embedded in their practice, while others would be challenged to adopt a new approach. Design: Qualitative, descriptive research design. Methods: Data were collected through focus groups held before and after implementation of the AT programme. Data were analysed using the framework method. The (COREQ) checklist was followed. Results: Four emergent themes described the influence of motivation on individuals\u27 beliefs and attitudes towards practice change, relationships within the ED context, delivery of education and management directives. Conclusion: Implementing practice change is more than just providing technical knowledge and includes changing individuals\u27 beliefs and attitudes. An understanding of adaptive challenge can assist in implementing practice change that involves the multidisciplinary team. Relevance to clinical practice: Results provide evidence as to how the adaptive challenge framework could be a suitable approach to manage potential enablers and barriers to implementing change within a multidisciplinary team in an acute hospital

A patient-centred model of care incorporating a palliative approach: A framework to meet the needs of people with advanced COPD?

BACKGROUND: Current models of care for people with advanced chronic obstructive pulmonary disease (COPD) have been demonstrated to be inadequate, particularly in areas such as advance care planning, symptom control and psychosocial and spiritual care. AIM: This paper aims to explore how a model of patient-centred care can incorporate a palliative approach to form a practical and useful framework for care that meets the needs of people with advanced COPD. DISCUSSION: There is increasing recognition of the need to provide active disease management at the same time as supportive care for people with chronic disease. A palliative approach can incorporate these two care imperatives but a number of barriers often make implementation problematic. A patient-centred care approach can help to address these barriers and is increasingly being seen as an appropriate framework for all healthcare service provision. Significant changes are required to health systems and service provision for this model of care to be implemented; specialist palliative care services can take a leading role in change management. CONCLUSION: Patient-centred care provides an appropriate framework for the development of a model of care for advanced COPD. It allows for a need-based approach to service provision, rather than the current prognosis-based system and brings patient and carer needs and concerns to the forefront of care.Crawford, Gregory B.; Burgess, Teresa A.; Young, Mary; Brooksbank, Mary A.; Brown, Margare

Learning from incident reports in the Australian medical imaging setting: handover and communication errors

Objective: To determine the type and nature of incidents occurring within medical imaging settings in Australia and identify strategies that could be engaged to reduce the risk of their re-occurrence. Methods: 71 search terms, related to clinical handover and communication, were applied to 3976 incidents in the Radiology Events Register. Detailed classification and thematic analysis of a subset of incidents that involved handover or communication (n=298) were undertaken to identify the most prevalent types of error and to make recommendations about patient safety initiatives in medical imaging. Results: Incidents occurred most frequently during patient preparation (34%), when requesting imaging (27%) and when communicating a diagnosis (23%). Frequent problems within each of these stages of the imaging cycle included: inadequate handover of patients (41%) or unsafe or inappropriate transfer of the patient to or from medical imaging (35%); incorrect information on the request form (52%); and delayed communication of a diagnosis (36%) or communication of a wrong diagnosis (36%). Conclusion: The handover of patients and clinical information to and from medical imaging is fraught with error, often compromising patient safety and resulting in communication of delayed or wrong diagnoses, unnecessary radiation exposure and a waste of limited resources. Corrective strategies to address safety concerns related to new information technologies, patient transfer and inadequate test result notification policies are relevant to all healthcare settings.N Hannaford, C Mandel, C Crock, K Buckley, F Magrabi, M Ong, S Allen, and T Schult

Antibiotic prescribing in primary healthcare: Dominant factors and trade-offs in decision-making

Background: This study aims to establish dominant factors influencing general practitioner (GP) decision-making on antibiotic prescribing in the Australian primary healthcare sector. Two research questions were posed: What influences antibiotic prescribing from the perspective of GPs? How do GPs trade-off on factors influencing antibiotic prescribing? Methods: An exploratory sequential mixed methods design was used, comprising semi-structured interviews followed by a discrete choice experiment (DCE). Ten GPs practising in Brisbane and Greater Brisbane, Queensland were interviewed in September/October 2015. Interview data were used to develop the DCE, which was conducted online from July–October 2016. Twenty-three GPs participated in the DCE. Results: Three main themes influencing antibiotic prescribing emerged from the semi-structured interviews: prescribing challenges, delayed antibiotic prescriptions, and patient expectations. From the DCE, “Duration of symptoms” and “Patient expectations” exerted the most influence on antibiotic prescribing. Taken together, these results suggest that key challenges to prudent antibiotic prescribing are: patient expectations, an important barrier which is surmountable; prescribing practices of medical colleagues, cultural memes and professional etiquette; and uncertainty of diagnosis coupled with patient expectations for antibiotics exert prescribing pressure on GPs. Conclusion: Patient expectation for antibiotics is the dominant modifiable factor influencing GP antibiotic prescribing behaviours. Key challenges to prudent antibiotic prescribing can be overcome through upskilling GPs to manage patient expectations efficaciously, and through two new emphases for public health campaigns—consumers have the power to reduce the use of antibiotics and the GP as a wise advocate for the patient